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General NPI Number Information
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NPI Number | 1689803041
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Entity Type | Individual
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Provider Name | SUSAN PRATER KUDLATS DMD
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Gender | Female
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Dates
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Enumeration Date | 07/07/2009
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Last Update Date | 03/25/2024
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Provider Practice Location Address
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Address Line | 12620 BEACH BLVD SUITE 18
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City | JACKSONVILLE
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State | FL
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Zip | 32246
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Country | US
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Telephone | 706-738-6516
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Fax | 706-262-6518
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Provider Business Mailing Address
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Address Line | 221 SPANISH CREEK DRIVE
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City | PONTE VEDRA
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State | FL
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Zip | 32081
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Country | US
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Telephone | 706-738-6516
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Fax | 706-262-6518
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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 | DN21768
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License Number State | FL
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