Provider Demographics
NPI:1518298231
Name:DR. SUSAN P EDDLEMAN
Entity Type:Organization
Organization Name:DR. SUSAN P EDDLEMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:EDDLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:660-744-5391
Mailing Address - Street 1:204 S MAIN ST
Mailing Address - Street 2:PO BOX 282
Mailing Address - City:ROCK PORT
Mailing Address - State:MO
Mailing Address - Zip Code:64482-1532
Mailing Address - Country:US
Mailing Address - Phone:660-744-5391
Mailing Address - Fax:660-744-5301
Practice Address - Street 1:204 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCK PORT
Practice Address - State:MO
Practice Address - Zip Code:64482-1532
Practice Address - Country:US
Practice Address - Phone:660-744-5391
Practice Address - Fax:660-744-5301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO14169261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental