Provider Demographics
NPI:1598854291
Name:CALDERBANK, SUSAN E (DMD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:CALDERBANK
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 1:43 CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125
Mailing Address - Country:US
Mailing Address - Phone:724-588-1600
Mailing Address - Fax:724-588-1608
Practice Address - Street 1:43 CLINTON ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16125
Practice Address - Country:US
Practice Address - Phone:724-588-1600
Practice Address - Fax:724-588-1608
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS020035L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000891546001Medicaid
033587OtherBLUE SHIELD