Provider Demographics
NPI:1821208166
Name:SUSOTT, KENTON A (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:KENTON
Middle Name:A
Last Name:SUSOTT
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3916 SHORE DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-2604
Mailing Address - Country:US
Mailing Address - Phone:317-299-9506
Mailing Address - Fax:317-290-3505
Practice Address - Street 1:3916 SHORE DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2604
Practice Address - Country:US
Practice Address - Phone:317-299-9506
Practice Address - Fax:317-290-3505
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006912A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics