Provider Demographics
NPI:1073695177
Name:SEKRETA, SUSAN (DDS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SEKRETA
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 1:103 BURROWS RD STE 1
Mailing Address - Street 2:
Mailing Address - City:WEST WINFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:13491-2830
Mailing Address - Country:US
Mailing Address - Phone:315-822-4321
Mailing Address - Fax:315-822-3284
Practice Address - Street 1:103 BURROWS RD STE 1
Practice Address - Street 2:
Practice Address - City:WEST WINFIELD
Practice Address - State:NY
Practice Address - Zip Code:13491-2830
Practice Address - Country:US
Practice Address - Phone:315-822-4321
Practice Address - Fax:315-822-3284
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0503691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02444255Medicaid