Provider Demographics
NPI:1922218395
Name:DRAHEIM, SUSAN (DDS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:DRAHEIM
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 1:716 RUSSELL AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46225-1216
Mailing Address - Country:US
Mailing Address - Phone:317-684-1997
Mailing Address - Fax:317-684-1994
Practice Address - Street 1:716 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46225-1216
Practice Address - Country:US
Practice Address - Phone:317-684-1997
Practice Address - Fax:317-684-1994
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ120094651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice