Provider Demographics
NPI:1932265055
Name:WALLENGREN, SUSANNE SCHOPPERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSANNE
Middle Name:SCHOPPERT
Last Name:WALLENGREN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 WEST JOPPA RD
Mailing Address - Street 2:SUITE 430
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093
Mailing Address - Country:US
Mailing Address - Phone:410-321-0200
Mailing Address - Fax:410-825-1159
Practice Address - Street 1:2324 WEST JOPPA RD
Practice Address - Street 2:SUITE 430
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093
Practice Address - Country:US
Practice Address - Phone:410-321-0200
Practice Address - Fax:410-825-1159
Is Sole Proprietor?:No
Enumeration Date:2007-01-01
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3351122300000X, 1223P0221X
MD12747122300000X, 1223P0221X
PADS0395491223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30304152Medicaid