Healthcare Provider Details

I. General information

NPI: 1457603045
Provider Name (Legal Business Name): SUSAN MARIE MEDCALF RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2012
Last Update Date: 10/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1371 N COUNTRYSIDE DR
JUNIATA NE
68955-3118
US

IV. Provider business mailing address

1371 N COUNTRYSIDE DR
JUNIATA NE
68955-3118
US

V. Phone/Fax

Practice location:
  • Phone: 402-902-8302
  • Fax:
Mailing address:
  • Phone: 402-902-8302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number1239
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: