Provider Demographics
NPI:1588746440
Name:NUTTLE, SUSAN LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LEE
Last Name:NUTTLE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 APPIAN WAY STE 303
Mailing Address - Street 2:
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2525
Mailing Address - Country:US
Mailing Address - Phone:510-724-5100
Mailing Address - Fax:510-724-8709
Practice Address - Street 1:2000 APPIAN WAY STE 303
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2525
Practice Address - Country:US
Practice Address - Phone:510-724-5100
Practice Address - Fax:510-724-8709
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42752122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist