Provider Demographics
NPI:1427270552
Name:SUSAN ELLISON DDS PC
Entity type:Organization
Organization Name:SUSAN ELLISON DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:ELLISON
Authorized Official - Last Name:KETTERER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:281-890-2828
Mailing Address - Street 1:12850 JONES RD
Mailing Address - Street 2:# 103
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070
Mailing Address - Country:US
Mailing Address - Phone:281-890-2828
Mailing Address - Fax:281-897-9793
Practice Address - Street 1:12850 JONES RD
Practice Address - Street 2:# 103
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070
Practice Address - Country:US
Practice Address - Phone:281-890-2828
Practice Address - Fax:281-897-9793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15975122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty