Healthcare Provider Details

I. General information

NPI: 1942322755
Provider Name (Legal Business Name): SUSAN LARAE WOOD DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 05/16/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10555 N TATUM BLVD STE A102
PARADISE VALLEY AZ
85253-1096
US

IV. Provider business mailing address

10555 N TATUM BLVD STE A102
PARADISE VALLEY AZ
85253-1096
US

V. Phone/Fax

Practice location:
  • Phone: 807-912-7334
  • Fax: 480-701-8400
Mailing address:
  • Phone: 480-438-4334
  • Fax: 505-819-5691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD009067
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: