Provider Demographics
NPI:1396836458
Name:SOCKWELL, SUSAN L (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:L
Last Name:SOCKWELL
Suffix:
Gender:F
Credentials:DMD
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 125
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-0003
Mailing Address - Country:US
Mailing Address - Phone:706-867-9553
Mailing Address - Fax:706-867-6307
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:706-867-6307
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0111191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice