Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 8889 | CO |
N | 1223D0004X | Dentist Anesthesiologist | 8889 | CO |
NPI | 1134234404 |
---|---|
Provider Name | Jennifer Wallen |
First Address | Aurora, CO 80040-0876 |
Second Address | Aurora, CO 80045-7106 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/08/2006 |
Last Update Date | 23/03/2017 |