Healthcare Provider Details

I. General information

NPI: 1255318556
Provider Name (Legal Business Name): SUSAN M CAMACHO DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 ALDEN RD
FAIRHAVEN MA
02719-4721
US

IV. Provider business mailing address

118 ALDEN RD
FAIRHAVEN MA
02719-4721
US

V. Phone/Fax

Practice location:
  • Phone: 508-994-2255
  • Fax: 508-992-5544
Mailing address:
  • Phone: 508-994-2255
  • Fax: 508-992-5544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number17747
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: