Provider Demographics
NPI:1447223573
Name:NEAL, SUSAN MARIE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:NEAL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10279 NW GRAY RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32430-2115
Mailing Address - Country:US
Mailing Address - Phone:850-674-1719
Mailing Address - Fax:
Practice Address - Street 1:232 EAST LAKE AVENUE
Practice Address - Street 2:
Practice Address - City:WEWAHITCHKA
Practice Address - State:FL
Practice Address - Zip Code:32465
Practice Address - Country:US
Practice Address - Phone:850-639-4414
Practice Address - Fax:850-639-5934
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH 18292124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist