Provider Demographics
NPI:1740618958
Name:SUMMERLIN, EMILY (DDS)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:SUMMERLIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:
Other - Last Name:WAMPLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:554 KEILY STREET
Mailing Address - Street 2:BUREAU OF MEDICINE AND SURGERY-CENTRALIZED CREDENTIALS
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32212
Mailing Address - Country:US
Mailing Address - Phone:757-953-7011
Mailing Address - Fax:
Practice Address - Street 1:554 KEILY STREET
Practice Address - Street 2:BUREAU OF MEDICINE AND SURGERY-CENTRALIZED CREDENTIALS
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212
Practice Address - Country:US
Practice Address - Phone:757-953-7011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-25
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012005A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist