Provider Demographics
NPI:1811245194
Name:WILHELM, SUSANA (DDS)
Entity type:Individual
Prefix:
First Name:SUSANA
Middle Name:
Last Name:WILHELM
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 1:841 NW 170TH TER
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-2124
Mailing Address - Country:US
Mailing Address - Phone:954-850-7858
Mailing Address - Fax:
Practice Address - Street 1:841 NW 170TH TER
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-2124
Practice Address - Country:US
Practice Address - Phone:954-850-7858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-17
Last Update Date:2015-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 20892122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist