Provider Demographics
NPI:1568535912
Name:PEROTKA, SUSAN JOY (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:JOY
Last Name:PEROTKA
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 1:3111 SOUTH KIMBROUGH AVENUE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MD
Mailing Address - Zip Code:65807-5011
Mailing Address - Country:US
Mailing Address - Phone:417-887-5661
Mailing Address - Fax:417-889-6814
Practice Address - Street 1:3111 SOUTH KIMBROUGH AVENUE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MD
Practice Address - Zip Code:65807-5011
Practice Address - Country:US
Practice Address - Phone:417-887-5661
Practice Address - Fax:417-889-6814
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO15224122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist