Provider Demographics
NPI:1063722643
Name:WALLANDER, CONSTANCE ANNIE (DMD)
Entity type:Individual
Prefix:DR
First Name:CONSTANCE
Middle Name:ANNIE
Last Name:WALLANDER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 TECKLA PL
Mailing Address - Street 2:
Mailing Address - City:KIEL
Mailing Address - State:WI
Mailing Address - Zip Code:53042-9623
Mailing Address - Country:US
Mailing Address - Phone:920-894-2305
Mailing Address - Fax:920-894-3048
Practice Address - Street 1:1250 TECKLA PL
Practice Address - Street 2:
Practice Address - City:KIEL
Practice Address - State:WI
Practice Address - Zip Code:53042-9623
Practice Address - Country:US
Practice Address - Phone:920-894-2305
Practice Address - Fax:920-894-3048
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6626-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist