Provider Demographics
NPI:1619298957
Name:GRANQUIST, SUSAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:GRANQUIST
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:KAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 MAPLE AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-1459
Mailing Address - Country:US
Mailing Address - Phone:570-251-6534
Mailing Address - Fax:570-251-6538
Practice Address - Street 1:600 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-1459
Practice Address - Country:US
Practice Address - Phone:570-251-6534
Practice Address - Fax:570-251-6538
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038265122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist