Provider Demographics
NPI:1629214291
Name:SHADA, SUSAN MARIE (RDH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:SHADA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11470 PARIS ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:CO
Mailing Address - Zip Code:80640-7614
Mailing Address - Country:US
Mailing Address - Phone:303-358-6092
Mailing Address - Fax:
Practice Address - Street 1:9197 GRANT ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-4361
Practice Address - Country:US
Practice Address - Phone:303-358-6092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-01
Last Update Date:2009-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH903675124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO20081649099OtherSTATE IDENTIFICATION NUMBER