Provider Demographics
NPI:1073626230
Name:SUSOTT, JON W (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:W
Last Name:SUSOTT
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 1:215 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074
Mailing Address - Country:US
Mailing Address - Phone:317-896-5353
Mailing Address - Fax:317-867-2315
Practice Address - Street 1:215 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074
Practice Address - Country:US
Practice Address - Phone:317-896-5353
Practice Address - Fax:317-867-2315
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008521A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist