Provider Demographics
NPI:1811325822
Name:BOTHWELL, SUSAN L (RDH)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:BOTHWELL
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 1:626 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-3520
Mailing Address - Country:US
Mailing Address - Phone:970-417-4414
Mailing Address - Fax:970-240-2724
Practice Address - Street 1:236 S 3RD ST
Practice Address - Street 2:#294
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-3618
Practice Address - Country:US
Practice Address - Phone:970-240-2720
Practice Address - Fax:970-240-2724
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-30
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO000902869124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist