Provider Demographics
NPI:1598020257
Name:MUTH, SUSAN DICKERSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:DICKERSON
Last Name:MUTH
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 1:1834 JAKE ALEXANDER BLVD W
Mailing Address - Street 2:SUITE 504
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28147-1135
Mailing Address - Country:US
Mailing Address - Phone:704-636-1848
Mailing Address - Fax:704-636-4890
Practice Address - Street 1:1834 JAKE ALEXANDER BLVD W
Practice Address - Street 2:SUITE 504
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-1135
Practice Address - Country:US
Practice Address - Phone:704-636-1848
Practice Address - Fax:704-636-4890
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413606122300000X
NC95731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist