Provider Demographics
NPI:1700925690
Name:PORT, SUZANNE K (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:K
Last Name:PORT
Suffix:
Gender:F
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:291 W LAKEWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424
Mailing Address - Country:US
Mailing Address - Phone:616-392-1100
Mailing Address - Fax:616-396-1117
Practice Address - Street 1:291 W LAKEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424
Practice Address - Country:US
Practice Address - Phone:616-392-1100
Practice Address - Fax:616-396-1117
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010185291223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry