Provider Demographics
NPI:1043979826
Name:GALVIS, SUSAN DIANE
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DIANE
Last Name:GALVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7870 WOODLAND CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-2409
Mailing Address - Country:US
Mailing Address - Phone:156-157-9958
Mailing Address - Fax:
Practice Address - Street 1:7870 WOODLAND CENTER BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2409
Practice Address - Country:US
Practice Address - Phone:156-157-9958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH28686124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist