Provider Demographics
NPI:1407152218
Name:FERREIRA-SUSIN, LISIANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISIANE
Middle Name:
Last Name:FERREIRA-SUSIN
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 1:1430 JOHN WESLEY GILBERT DR
Mailing Address - Street 2:GC-1024
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:706-721-4225
Mailing Address - Fax:
Practice Address - Street 1:1430 JOHN WESLEY GILBERT DRIVE
Practice Address - Street 2:GC-1024
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-1001
Practice Address - Country:US
Practice Address - Phone:706-721-4225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-27
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNF0003581223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZG0358Medicaid
SCZG0358Medicaid