Provider Demographics
NPI:1093866477
Name:PARK, SUSAN N (DMD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:N
Last Name:PARK
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 1:1661 ESTERO BLVD
Mailing Address - Street 2:SUITE 29
Mailing Address - City:FORT MYERS BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33931-2846
Mailing Address - Country:US
Mailing Address - Phone:239-463-5433
Mailing Address - Fax:239-463-0114
Practice Address - Street 1:1661 ESTERO BLVD
Practice Address - Street 2:SUITE 29
Practice Address - City:FORT MYERS BEACH
Practice Address - State:FL
Practice Address - Zip Code:33931-2846
Practice Address - Country:US
Practice Address - Phone:239-463-5433
Practice Address - Fax:239-463-0114
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN125381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice