=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689729576
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN LEVINE DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 52 BEACH RD SUITE 203
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06824-6017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-259-7073
-----------------------------------------------------
Fax | 203-259-4069
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 52 BEACH RD SUITE 203
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06824-6017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-259-7073
-----------------------------------------------------
Fax | 203-259-4069
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 006218
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------