Provider Demographics
NPI:1134243256
Name:LANCE, SUSAN TAYLOR (DDS)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:TAYLOR
Last Name:LANCE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:RENEE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:5207 REGAL WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-9050
Mailing Address - Country:US
Mailing Address - Phone:252-671-2667
Mailing Address - Fax:
Practice Address - Street 1:5207 REGAL WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-9050
Practice Address - Country:US
Practice Address - Phone:252-671-2667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015015768122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2015015768OtherSTATE LICENSE
NC6581OtherDENTAL LICENSE NUMBER