Provider Demographics
NPI:1942642525
Name:MIKKELSON, SUSANNA KAY (RDH)
Entity Type:Individual
Prefix:
First Name:SUSANNA
Middle Name:KAY
Last Name:MIKKELSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W286N991 SHEPHERDS WAY
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-9493
Mailing Address - Country:US
Mailing Address - Phone:262-896-9891
Mailing Address - Fax:262-347-4449
Practice Address - Street 1:W286N991 SHEPHERDS WAY
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-9493
Practice Address - Country:US
Practice Address - Phone:262-896-9891
Practice Address - Fax:262-347-4449
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
6735-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist