Provider Demographics
NPI:1083782254
Name:JOHN, CAROLYN SUZANNE (DDS)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:SUZANNE
Last Name:JOHN
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 1:3226 HIDDEN TIMBER DR STE B
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48359-1598
Mailing Address - Country:US
Mailing Address - Phone:248-393-1888
Mailing Address - Fax:248-393-1890
Practice Address - Street 1:3226 HIDDEN TIMBER DR STE B
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48359-1598
Practice Address - Country:US
Practice Address - Phone:248-393-1888
Practice Address - Fax:248-393-1890
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010188141223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
V02462Medicare UPIN