Provider Demographics
NPI:1427174135
Name:SHOULTS, SUSAN LEAKE (DDS)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEAKE
Last Name:SHOULTS
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 1:2910 MELTON AVE
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39581-4120
Mailing Address - Country:US
Mailing Address - Phone:228-762-9250
Mailing Address - Fax:228-762-1785
Practice Address - Street 1:2910 MELTON AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-4120
Practice Address - Country:US
Practice Address - Phone:228-762-9250
Practice Address - Fax:228-762-1785
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS292396122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist