Provider Demographics
NPI:1083650436
Name:RUSSETT-COLLETT, SUSAN J (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:J
Last Name:RUSSETT-COLLETT
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 1:3 LEDGE HILL RD
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-2121
Mailing Address - Country:US
Mailing Address - Phone:207-839-8149
Mailing Address - Fax:
Practice Address - Street 1:888 BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1004
Practice Address - Country:US
Practice Address - Phone:207-772-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME30081223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry