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General NPI Number Information
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NPI Number | 1093857799
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Entity Type | Individual
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Provider Name | SUSAN J SUP DDS
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Gender | Female
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Dates
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Enumeration Date | 02/12/2007
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Last Update Date | 10/01/2025
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Provider Practice Location Address
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Address Line | 302 S PINE ST
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City | GRANTSBURG
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State | WI
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Zip | 54840-7930
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Country | US
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Telephone | 315-657-2719
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Fax |
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Provider Business Mailing Address
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Address Line | 302 S PINE ST STE 203
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City | GRANTSBURG
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State | WI
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Zip | 54840-7930
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 1917286
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 6001364-15
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License Number State | WI
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