Basic Information
| Provider Information | |||||||||
| NPI: | 1083271704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLAERT | ||||||||
| FirstName: | DEANNE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PHDHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1223 LOCUST ST 3RD FL | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159854448 | ||||||||
| FaxNumber: | 2159854952 | ||||||||
| Practice Location | |||||||||
| Address1: | 1207 CHESTNUT ST 4TH FL | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155253046 | ||||||||
| FaxNumber: | 2155671617 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2019 | ||||||||
| LastUpdateDate: | 05/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | DH069570 | PA | N | Dental Providers | Dental Hygienist | 1223D0001X | PHDH000393 | PA | Y | Dental Providers | Dentist | Dental Public Health |
No ID Information.