Provider Demographics
NPI:1780717066
Name:NILES, SUSAN MARIE
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:NILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:NILES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:14707 CALIFORNIA STREET
Mailing Address - Street 2:SEVILLE SQUARE OFFICE BUILDING SUITE 15
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-1900
Mailing Address - Country:US
Mailing Address - Phone:402-498-0777
Mailing Address - Fax:402-498-0853
Practice Address - Street 1:14707 CALIFORNIA STREET
Practice Address - Street 2:SEVILLE SQUARE OFFICE BUILDING SUITE 15
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-1900
Practice Address - Country:US
Practice Address - Phone:402-498-0777
Practice Address - Fax:402-498-0853
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE53351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470727849OtherBLUE CROSS BLUE SHIELD IN