Provider Demographics
NPI:1538290325
Name:MALECEK, SUSAN PATRICE (RDH)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:PATRICE
Last Name:MALECEK
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 1:14929 191ST AVE NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-7956
Mailing Address - Country:US
Mailing Address - Phone:763-441-6253
Mailing Address - Fax:
Practice Address - Street 1:16991 198TH AVENUE NW
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-0249
Practice Address - Country:US
Practice Address - Phone:763-263-6350
Practice Address - Fax:763-263-0136
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH5338124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist