Provider Demographics
NPI:1164436531
Name:WILSON, SUSAN E (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:E
Last Name:WILSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:E
Other - Last Name:BUTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:6816 HEYL RD
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-9728
Mailing Address - Country:US
Mailing Address - Phone:440-526-3030
Mailing Address - Fax:
Practice Address - Street 1:10000 BRECKSVILLE RD
Practice Address - Street 2:
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141-3204
Practice Address - Country:US
Practice Address - Phone:440-526-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH173101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice