Provider Demographics
NPI:1184610909
Name:EDDLEMAN, SUSAN PANCOAST (DDS)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:PANCOAST
Last Name:EDDLEMAN
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 1:204 S MAIN ST
Mailing Address - Street 2:P. O. BOX 282
Mailing Address - City:ROCK PORT
Mailing Address - State:MO
Mailing Address - Zip Code:64482-1532
Mailing Address - Country:US
Mailing Address - Phone:660-744-5391
Mailing Address - Fax:
Practice Address - Street 1:204 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCK PORT
Practice Address - State:MO
Practice Address - Zip Code:64482-1532
Practice Address - Country:US
Practice Address - Phone:660-744-5391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO141691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO13627011OtherBCBS OF KANSAS CITY