Provider Demographics
NPI:1043564289
Name:DELILLE, SUMMER SUZANNE (RDH)
Entity Type:Individual
Prefix:
First Name:SUMMER
Middle Name:SUZANNE
Last Name:DELILLE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95054 ORIOLE ST.
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034
Mailing Address - Country:US
Mailing Address - Phone:912-409-2650
Mailing Address - Fax:
Practice Address - Street 1:95054 ORIOLE ST.
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034
Practice Address - Country:US
Practice Address - Phone:912-409-2650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH22275124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist