Provider Demographics
NPI:1467796920
Name:WORM, SUSAN (DMD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WORM
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 1:4811 NW 1ST ST
Mailing Address - Street 2:STE 4
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68521-4549
Mailing Address - Country:US
Mailing Address - Phone:402-435-7700
Mailing Address - Fax:
Practice Address - Street 1:6040 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-6640
Practice Address - Country:US
Practice Address - Phone:402-817-2783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-21
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7056122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist