Provider Demographics
NPI:1134128242
Name:RODEFFER, SUELLEN (DDS)
Entity Type:Individual
Prefix:
First Name:SUELLEN
Middle Name:
Last Name:RODEFFER
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 1:1884 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-3054
Mailing Address - Country:US
Mailing Address - Phone:904-261-2156
Mailing Address - Fax:904-261-4843
Practice Address - Street 1:1884 S 14TH ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-3054
Practice Address - Country:US
Practice Address - Phone:904-261-2156
Practice Address - Fax:904-261-4843
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN89631223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics