Basic Information
| Provider Information | |||||||||
| NPI: | 1629639349 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 128 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | ALAMOSA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811012290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195899691 | ||||||||
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| Practice Location | |||||||||
| Address1: | 707 US HIGHWAY 24 N | ||||||||
| Address2: | |||||||||
| City: | BUENA VISTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812119863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193958610 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2019 | ||||||||
| LastUpdateDate: | 08/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DEN.00204062 | CO | Y | Dental Providers | Dentist | General Practice |
No ID Information.