Provider Demographics
NPI:1104544782
Name:DAVIDSON, SUSAN AGNES (DDS)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:AGNES
Last Name:DAVIDSON
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 1:7355 WINDING OAKS DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-2547
Mailing Address - Country:US
Mailing Address - Phone:813-494-0091
Mailing Address - Fax:
Practice Address - Street 1:7903 SILICON HTS
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80939-9734
Practice Address - Country:US
Practice Address - Phone:719-354-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00205289122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist