Provider Demographics
NPI:1104963826
Name:EBERT, SUZANNE M (DMD, FAGD)
Entity type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:M
Last Name:EBERT
Suffix:
Gender:F
Credentials:DMD, FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 SAWGRASS CORNERS DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-3553
Mailing Address - Country:US
Mailing Address - Phone:904-543-0568
Mailing Address - Fax:
Practice Address - Street 1:151 SAWGRASS CORNERS DR
Practice Address - Street 2:SUITE 102
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-3553
Practice Address - Country:US
Practice Address - Phone:904-543-0568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL148461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice