Provider Demographics
NPI:1114309986
Name:WOFFORD, SUSAN EARNESTINE (DMD)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:EARNESTINE
Last Name:WOFFORD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:WOFFORD
Other - Last Name:HIMSCHOOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:2241 STATE STREET
Mailing Address - Street 2:SUITE C
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150
Mailing Address - Country:US
Mailing Address - Phone:812-945-5100
Mailing Address - Fax:502-459-4226
Practice Address - Street 1:415 BENJAMIN LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5813
Practice Address - Country:US
Practice Address - Phone:502-423-7868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9716122300000X
IN12013505A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist