Provider Demographics
NPI:1720393168
Name:ST GEORGE, SUSAN E (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:E
Last Name:ST GEORGE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 GOODRICH AVE
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-2119
Mailing Address - Country:US
Mailing Address - Phone:804-861-5237
Mailing Address - Fax:804-861-1601
Practice Address - Street 1:23 GOODRICH AVE
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-2119
Practice Address - Country:US
Practice Address - Phone:804-861-5237
Practice Address - Fax:804-861-1601
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014124981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice