Provider Demographics
NPI:1164834107
Name:SUSAN L SOCKWELL DMD PC
Entity Type:Organization
Organization Name:SUSAN L SOCKWELL DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SOCKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-867-9553
Mailing Address - Street 1:104 ANSLEY DR
Mailing Address - Street 2:P O BOX 125
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-1614
Mailing Address - Country:US
Mailing Address - Phone:706-867-9553
Mailing Address - Fax:
Practice Address - Street 1:104 ANSLEY DR
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-1614
Practice Address - Country:US
Practice Address - Phone:706-867-9553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-26
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011119122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7155750001Medicare NSC