Provider Demographics
NPI:1467494427
Name:COTTRELL, SUSAN GAIL (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:GAIL
Last Name:COTTRELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:COTTRELL
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3799 E CR 30A
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BCH
Mailing Address - State:FL
Mailing Address - Zip Code:34259
Mailing Address - Country:US
Mailing Address - Phone:850-586-2043
Mailing Address - Fax:
Practice Address - Street 1:LECOM
Practice Address - Street 2:101 LECOM WAY
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435
Practice Address - Country:US
Practice Address - Phone:850-951-0200
Practice Address - Fax:850-951-6706
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 130501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice