MEDICARE: SUSAN L SOCKWELL DMD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BC3200X	Customized Equipment (DME)
2	122300000X	Dentist	011119	GA

General Provider Information

NPI Number	:	1164834107
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUSAN L SOCKWELL DMD PC

Provider Business Mailing Address
First Line	:	104 ANSLEY DR
Second Line	:	P O BOX 125
City	:	DAHLONEGA
State	:	GA
Zip	:	30533-1614
Country	:	US
Telephone Number	:	706-867-9553
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 ANSLEY DR
Second Line	:
City	:	DAHLONEGA
State	:	GA
Zip	:	30533-1614
Country	:	US
Telephone Number	:	706-867-9553
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SUSAN L SOCKWELL
Credential	:
Telephone Number	:	706-867-9553

Provider Enumeration Date	:	05/26/2014
Last Update Date	:	08/20/2014

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