Provider Demographics
NPI:1740393925
Name:SMITH, SUSAN CONNIE (DMD, PC)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:CONNIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:DMD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5805 SE MILWAUKIE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-5255
Mailing Address - Country:US
Mailing Address - Phone:503-233-5825
Mailing Address - Fax:503-239-7268
Practice Address - Street 1:5805 SE MILWAUKIE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-5255
Practice Address - Country:US
Practice Address - Phone:503-233-5825
Practice Address - Fax:503-239-7268
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice