Provider Demographics
NPI:1336319292
Name:DEBRUYNE, SUSAN GAIL (RDH)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:GAIL
Last Name:DEBRUYNE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-5337
Mailing Address - Country:US
Mailing Address - Phone:715-394-5411
Mailing Address - Fax:715-392-5086
Practice Address - Street 1:3600 TOWER AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5337
Practice Address - Country:US
Practice Address - Phone:715-394-5411
Practice Address - Fax:715-392-5086
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002091-016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist