Provider Demographics
NPI:1720188378
Name:EDWARDS, SUZANNE E (DMD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:E
Last Name:EDWARDS
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 1:15 W WATER ST
Mailing Address - Street 2:
Mailing Address - City:LOCK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17745-1250
Mailing Address - Country:US
Mailing Address - Phone:570-748-3595
Mailing Address - Fax:570-748-9622
Practice Address - Street 1:15 W WATER ST
Practice Address - Street 2:
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745-1250
Practice Address - Country:US
Practice Address - Phone:570-748-3595
Practice Address - Fax:570-748-9622
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS028115L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012906580001Medicaid
PA724917OtherUCCI PROVIDER #