Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | PHDH000393 | PA |
N | 124Q00000X | Dental Hygienist | DH069570 | PA |
NPI | 1083271704 |
---|---|
Provider Name | Ms. Deanne Wallaert |
First Address | Philadelphia, PA 19107-5400 |
Second Address | Philadelphia, PA 19107-4131 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/05/2019 |
Last Update Date | 29/05/2019 |