Provider Demographics
NPI:1720573082
Name:MERCHANT, SUSAN EVELYN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:EVELYN
Last Name:MERCHANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N3710 COUNTY HIGHWAY K
Mailing Address - Street 2:
Mailing Address - City:SHELL LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54871-8660
Mailing Address - Country:US
Mailing Address - Phone:715-416-0701
Mailing Address - Fax:
Practice Address - Street 1:4404 STATE ROAD 70
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:WI
Practice Address - Zip Code:54893-9251
Practice Address - Country:US
Practice Address - Phone:715-349-8554
Practice Address - Fax:715-349-2504
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6329-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist