Provider Demographics
NPI:1043211238
Name:LOCKE, SUSAN DAHL (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:DAHL
Last Name:LOCKE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6060 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-4544
Mailing Address - Country:US
Mailing Address - Phone:210-828-9666
Mailing Address - Fax:210-828-3119
Practice Address - Street 1:6060 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-4544
Practice Address - Country:US
Practice Address - Phone:210-828-9666
Practice Address - Fax:210-828-3119
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX140891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice