Provider Demographics
NPI:1235638586
Name:SUSALLA, JILL A
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:A
Last Name:SUSALLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8326 N SAGINAW RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT MORRIS
Mailing Address - State:MI
Mailing Address - Zip Code:48458-1648
Mailing Address - Country:US
Mailing Address - Phone:810-687-5040
Mailing Address - Fax:810-687-5130
Practice Address - Street 1:8326 N SAGINAW RD
Practice Address - Street 2:
Practice Address - City:MOUNT MORRIS
Practice Address - State:MI
Practice Address - Zip Code:48458-1648
Practice Address - Country:US
Practice Address - Phone:810-687-5040
Practice Address - Fax:810-687-5130
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI290200403124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist