Provider Demographics
NPI:1457432411
Name:ERMISH, SUSAN D (DMD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:ERMISH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 E 16TH ST
Mailing Address - Street 2:
Mailing Address - City:BERWICK
Mailing Address - State:PA
Mailing Address - Zip Code:18603-2402
Mailing Address - Country:US
Mailing Address - Phone:570-752-0840
Mailing Address - Fax:570-752-6806
Practice Address - Street 1:105 W 9TH ST
Practice Address - Street 2:
Practice Address - City:BERWICK
Practice Address - State:PA
Practice Address - Zip Code:18603-3024
Practice Address - Country:US
Practice Address - Phone:570-752-4542
Practice Address - Fax:570-752-6806
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS030328L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018705690001Medicaid