Provider Demographics
NPI:1083715452
Name:ALSTON, SUSAN MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:ALSTON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 E MAIN ST
Mailing Address - Street 2:#1
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7404
Mailing Address - Country:US
Mailing Address - Phone:541-779-6401
Mailing Address - Fax:541-608-6814
Practice Address - Street 1:1117 E MAIN ST
Practice Address - Street 2:#1
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7404
Practice Address - Country:US
Practice Address - Phone:541-779-6401
Practice Address - Fax:541-608-6814
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD57081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice