Basic Information
Provider Information | |||||||||
NPI: | 1992857601 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HJORT | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RESCH | ||||||||
OtherFirstName: | SUSAN | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DDS | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 927 TRETTEL LN | ||||||||
Address2: |   | ||||||||
City: | CLOQUET | ||||||||
State: | MN | ||||||||
PostalCode: | 557201345 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2188791227 | ||||||||
FaxNumber: | 2188783800 | ||||||||
Practice Location | |||||||||
Address1: | FOND DU LAC HUMAN SERVICES DIVISION | ||||||||
Address2: | 927 TRETTEL LANE | ||||||||
City: | CLOQUET | ||||||||
State: | MN | ||||||||
PostalCode: | 55720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2188791227 | ||||||||
FaxNumber: | 2188782188 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/16/2007 | ||||||||
LastUpdateDate: | 11/28/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0001X | D10797 | MN | Y |   | Dental Providers | Dentist | Dental Public Health |
ID Information
ID | Type | State | Issuer | Description | BH4732308 | 01 | MN | DEA | OTHER | 983227100 | 05 | MN |   | MEDICAID |