Provider Demographics
NPI:1093832834
Name:SUSANVILLE DENTAL CARE
Entity Type:Organization
Organization Name:SUSANVILLE DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WEGER
Authorized Official - Last Name:HODGE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:530-257-7256
Mailing Address - Street 1:720 ASH ST
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-3716
Mailing Address - Country:US
Mailing Address - Phone:530-257-7256
Mailing Address - Fax:530-257-3546
Practice Address - Street 1:720 ASH ST
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-3716
Practice Address - Country:US
Practice Address - Phone:530-257-7256
Practice Address - Fax:530-257-3546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty