MEDICARE: MRS. SUSAN MARIE NEAL R.D.H.

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	124Q00000X	Dental Hygienist	DH 18292	FL

General Provider Information

NPI Number	:	1447223573
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN MARIE NEAL R.D.H.

Provider Business Mailing Address
First Line	:	10279 NW GRAY RD
Second Line	:
City	:	CLARKSVILLE
State	:	FL
Zip	:	32430-2115
Country	:	US
Telephone Number	:	850-674-1719
Fax Number	:

Provider Business Practice Location Address
First Line	:	232 EAST LAKE AVENUE
Second Line	:
City	:	WEWAHITCHKA
State	:	FL
Zip	:	32465
Country	:	US
Telephone Number	:	850-639-4414
Fax Number	:	850-639-5934

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2006
Last Update Date	:	07/08/2007

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