Provider Demographics
NPI:1952925497
Name:KING, SUSAN LYNN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 SUTTLE ST
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-8276
Mailing Address - Country:US
Mailing Address - Phone:970-335-2232
Mailing Address - Fax:970-335-2438
Practice Address - Street 1:2530 COLORADO AVE STE A
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-4760
Practice Address - Country:US
Practice Address - Phone:970-335-2442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002025760124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist