Provider Demographics
NPI:1366725582
Name:SUSANNE O. CORE DMD PDC FAMILY DENTISTRY
Entity type:Organization
Organization Name:SUSANNE O. CORE DMD PDC FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:O
Authorized Official - Last Name:CORE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:985-630-6906
Mailing Address - Street 1:73193 HWY 25
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70435
Mailing Address - Country:US
Mailing Address - Phone:985-630-6906
Mailing Address - Fax:985-796-5315
Practice Address - Street 1:73193 HWY 25
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70435
Practice Address - Country:US
Practice Address - Phone:985-630-6906
Practice Address - Fax:985-796-5315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3600122300000X
MS2392122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty