Provider Demographics
NPI:1922488352
Name:SUSAN A SHEETS DDS A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:SUSAN A SHEETS DDS A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEETS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-832-2657
Mailing Address - Street 1:2515 S WESTERN AVE
Mailing Address - Street 2:STE 109
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-4643
Mailing Address - Country:US
Mailing Address - Phone:310-832-2657
Mailing Address - Fax:310-832-5164
Practice Address - Street 1:2515 S WESTERN AVE
Practice Address - Street 2:STE 109
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-4643
Practice Address - Country:US
Practice Address - Phone:310-832-2657
Practice Address - Fax:310-832-5164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-01
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty