Provider Demographics
NPI:1497891824
Name:YAVNER, SUSAN BETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:BETH
Last Name:YAVNER
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 1:101 MAIN STREET SUITE #220
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155
Mailing Address - Country:US
Mailing Address - Phone:781-396-2179
Mailing Address - Fax:
Practice Address - Street 1:101 MAIN STREET SUITE #220
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155
Practice Address - Country:US
Practice Address - Phone:781-396-2179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA168321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0269948Medicaid