Susanne S. Wallengren, DDS, LLC

Primary specialty

Pediatric DentistryTaxonomy code 1223P0221X

License

12747 Issued in MD

Legal business name

SUSANNE S. WALLENGREN, DDS, LLC

Practice address

2324 W Joppa Rd
Suite 430
Lutherville, MD 21093-4615

Phone

(410) 321-0200

NPI assigned

Sep 9, 2015

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Lisa Black

Title

Practice Administrator

Phone

(410) 321-0200

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Joppa Green Pediatric Dentistry Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1441756800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1441756800000",
    "number": "1851769731",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2324 W JOPPA RD",
            "address_2": "SUITE 430",
            "city": "LUTHERVILLE",
            "state": "MD",
            "postal_code": "210934615",
            "telephone_number": "410-321-0200"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2324 W JOPPA RD",
            "address_2": "SUITE 430",
            "city": "LUTHERVILLE",
            "state": "MD",
            "postal_code": "210934615",
            "telephone_number": "410-321-0200"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SUSANNE S. WALLENGREN, DDS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-09-09",
        "last_updated": "2015-09-09",
        "status": "A",
        "authorized_official_last_name": "BLACK",
        "authorized_official_first_name": "LISA",
        "authorized_official_title_or_position": "PRACTICE ADMINISTRATOR",
        "authorized_official_telephone_number": "410-321-0200"
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "MD",
            "license": "12747",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "040520500",
            "state": "MD"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Joppa Green Pediatric Dentistry",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Pediatric Dentistry in Lutherville, MD
• Providers in Lutherville, MD by specialty
• Pediatric Dentistry in Maryland

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 9, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.