Provider Demographics
NPI:1609950518
Name:CORE, SUSANNE O (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSANNE
Middle Name:O
Last Name:CORE
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 1:73193 HWY 25
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70435
Mailing Address - Country:US
Mailing Address - Phone:985-630-6906
Mailing Address - Fax:985-796-5315
Practice Address - Street 1:73193 HWY 25
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70435
Practice Address - Country:US
Practice Address - Phone:985-630-6906
Practice Address - Fax:985-796-5315
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2392-88122300000X
LA49241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060246Medicaid