1750555793 NPI number — JILLIAN ALEXANDRA WALLEN B.D.S.

Table of content: JILLIAN ALEXANDRA WALLEN B.D.S. (NPI 1750555793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750555793 NPI number — JILLIAN ALEXANDRA WALLEN B.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLEN
Provider First Name:
JILLIAN
Provider Middle Name:
ALEXANDRA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
B.D.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EASTON
Provider Other First Name:
JILLIAN
Provider Other Middle Name:
ALEXANDRA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
B.D.S.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1750555793
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
444 SO. 44TH STREET
Provider Second Line Business Mailing Address:
UNMC PEDIATRIC DENTISTRY
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68198-5450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-559-7954
Provider Business Mailing Address Fax Number:
402-559-9307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
444 SO. 44TH STREET
Provider Second Line Business Practice Location Address:
UNMC PEDIATRIC DENTISTRY
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68198-5450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-559-7954
Provider Business Practice Location Address Fax Number:
402-559-9307
Provider Enumeration Date:
04/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  LL539 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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