Healthcare Provider Details

I. General information

NPI: 1952394439
Provider Name (Legal Business Name): SUSAN L SHORE-VIGNOLA D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 05/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 S CANAL ST
LAKE CITY MI
49651-7929
US

IV. Provider business mailing address

PO BOX 719
LAKE CITY MI
49651-0719
US

V. Phone/Fax

Practice location:
  • Phone: 231-839-2630
  • Fax: 231-839-5751
Mailing address:
  • Phone: 231-839-2630
  • Fax: 231-839-5751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901014317
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: