Healthcare Provider Details

I. General information

NPI: 1962324855
Provider Name (Legal Business Name): SAUSHA MANNON DENTURIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 N 4TH ST
COEUR D ALENE ID
83814-3216
US

IV. Provider business mailing address

1119 N 4TH ST
COEUR D ALENE ID
83814-3216
US

V. Phone/Fax

Practice location:
  • Phone: 208-667-8997
  • Fax:
Mailing address:
  • Phone: 208-667-8997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License Number7381926
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: