Provider Demographics
NPI:1205843620
Name:CADDELL, SUSAN GLENN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:GLENN
Last Name:CADDELL
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:PO BOX 677
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-0677
Mailing Address - Country:US
Mailing Address - Phone:352-343-2821
Mailing Address - Fax:352-343-0440
Practice Address - Street 1:109 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-3809
Practice Address - Country:US
Practice Address - Phone:352-343-2821
Practice Address - Fax:352-343-0440
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL94361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice