Basic Information
Provider Information | |||||||||
NPI: | 1265714851 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CAMMANN | ||||||||
FirstName: | SUSANNA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GRIMM | ||||||||
OtherFirstName: | SUSANNA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 652 HAMILTON ROAD | ||||||||
Address2: |   | ||||||||
City: | LAWTON | ||||||||
State: | OK | ||||||||
PostalCode: | 73503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5804424002 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 605 RANDOLPH RD | ||||||||
Address2: |   | ||||||||
City: | LAWTON | ||||||||
State: | OK | ||||||||
PostalCode: | 735034535 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5804424002 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/09/2011 | ||||||||
LastUpdateDate: | 09/09/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 60797 | CA | Y |   | Dental Providers | Dentist |   |
ID Information
ID | Type | State | Issuer | Description | 60797 | 01 | CA | DENTAL LICENSE | OTHER |