Organization
SUSANNE S. WALLENGREN, DDS, LLC
Active
Other names
Joppa Green Pediatric Dentistry
Organization subpart
No
Provider details
NPI number
Authorized official
LISA BLACK (PRACTICE ADMINISTRATOR)
(410) 321-0200
Entity
Organization
Contact information
Practice address
2324 W JOPPA RD, SUITE 430, LUTHERVILLE, MD 21093-4615
(410) 321-0200
Mailing address
2324 W JOPPA RD, SUITE 430, LUTHERVILLE, MD 21093-4615
(410) 321-0200
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
12747
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
040520500
—
MD
Enumeration date
09/09/2015
Last updated
09/09/2015
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