Provider Demographics
NPI:1558360552
Name:WELCH, SUSAN M (DDS)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:WELCH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 WRIGHT PKWY SE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548
Mailing Address - Country:US
Mailing Address - Phone:850-243-1534
Mailing Address - Fax:850-243-7541
Practice Address - Street 1:106 WRIGHT PKWY SE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548
Practice Address - Country:US
Practice Address - Phone:850-243-1534
Practice Address - Fax:850-243-7541
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN158211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL66466OtherBCBS