Provider Demographics
NPI:1275549313
Name:ANDERSON, SUSAN P (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:P
Last Name:ANDERSON
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 1:5412 BRIDGE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-8571
Mailing Address - Country:US
Mailing Address - Phone:815-623-1900
Mailing Address - Fax:815-623-1933
Practice Address - Street 1:5412 BRIDGE ST
Practice Address - Street 2:SUITE A
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-8571
Practice Address - Country:US
Practice Address - Phone:815-623-1900
Practice Address - Fax:815-623-1933
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19024372122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist