Provider Demographics
NPI:1629087408
Name:LOUISSE, SUSAN ALVAREZ (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ALVAREZ
Last Name:LOUISSE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ISABEL
Other - Last Name:ALVAREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2215 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40212-1033
Mailing Address - Country:US
Mailing Address - Phone:502-772-8160
Mailing Address - Fax:502-772-8189
Practice Address - Street 1:2215 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-1033
Practice Address - Country:US
Practice Address - Phone:502-772-8160
Practice Address - Fax:502-772-8189
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000093441223G0001X
KY86811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5039680Medicaid