Provider Demographics
NPI:1003970864
Name:NISSLEY, SUSAN M (DDS)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:NISSLEY
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 1:2052 LAWRENCEVILLE SUWANEE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-2647
Mailing Address - Country:US
Mailing Address - Phone:770-962-8253
Mailing Address - Fax:
Practice Address - Street 1:2052 LAWRENCEVILLE SUWANEE RD
Practice Address - Street 2:SUITE A
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-2647
Practice Address - Country:US
Practice Address - Phone:770-962-8253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0105061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice