Provider Demographics
NPI:1487851614
Name:STOVALL, SUSAN MARY (DENTURIST LD)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARY
Last Name:STOVALL
Suffix:
Gender:F
Credentials:DENTURIST LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16130 SE 82ND DRIVE
Mailing Address - Street 2:SWISS DENTURE CENTER
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-9587
Mailing Address - Country:US
Mailing Address - Phone:503-657-6500
Mailing Address - Fax:
Practice Address - Street 1:16130 SE 82ND DRIVE
Practice Address - Street 2:SWISS DENTURE CENTER
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97014
Practice Address - Country:US
Practice Address - Phone:503-657-6500
Practice Address - Fax:503-557-0412
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT DO 981893122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist