Provider Demographics
NPI:1699022988
Name:PETERS, SUSAN DELAINE (RDH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DELAINE
Last Name:PETERS
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 1:6110 36TH ST
Mailing Address - Street 2:UNIT 16
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-3649
Mailing Address - Country:US
Mailing Address - Phone:806-544-4757
Mailing Address - Fax:
Practice Address - Street 1:4215 85TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-1931
Practice Address - Country:US
Practice Address - Phone:806-794-1131
Practice Address - Fax:806-794-1103
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12681124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist