Provider Demographics
NPI:1093826265
Name:DENNIS, SUSAN M (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:DENNIS
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 1:8150 MOORSBRIDGE ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024
Mailing Address - Country:US
Mailing Address - Phone:269-327-3400
Mailing Address - Fax:269-327-6810
Practice Address - Street 1:8150 MOORSBRIDGE ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024
Practice Address - Country:US
Practice Address - Phone:269-327-3400
Practice Address - Fax:269-327-6810
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901012474122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist