Provider Demographics
NPI:1265714851
Name:CAMMANN, SUSANNA (DDS)
Entity type:Individual
Prefix:
First Name:SUSANNA
Middle Name:
Last Name:CAMMANN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SUSANNA
Other - Middle Name:
Other - Last Name:GRIMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:652 HAMILTON ROAD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73503
Mailing Address - Country:US
Mailing Address - Phone:580-442-4002
Mailing Address - Fax:
Practice Address - Street 1:605 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73503-4535
Practice Address - Country:US
Practice Address - Phone:580-442-4002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60797122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA60797OtherDENTAL LICENSE