Provider Demographics
NPI:1679603773
Name:POULSEN, WENDALL PETER (DDS)
Entity type:Individual
Prefix:DR
First Name:WENDALL
Middle Name:PETER
Last Name:POULSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 BLACKBURN LN
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BURTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20866-6136
Mailing Address - Country:US
Mailing Address - Phone:301-421-9001
Mailing Address - Fax:301-421-9772
Practice Address - Street 1:4040 BLACKBURN LN
Practice Address - Street 2:SUITE 180
Practice Address - City:BURTONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20866-6136
Practice Address - Country:US
Practice Address - Phone:301-421-9001
Practice Address - Fax:301-421-9772
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD09165122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist