Provider Demographics
NPI:1801809421
Name:MAUK, SUSAN H (DDS)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:H
Last Name:MAUK
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 1:340 LANE 150 LITTLE OTTER LK
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:IN
Mailing Address - Zip Code:46737-9793
Mailing Address - Country:US
Mailing Address - Phone:260-833-2886
Mailing Address - Fax:
Practice Address - Street 1:1003 W TOLEDO STREET
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:IN
Practice Address - Zip Code:46737
Practice Address - Country:US
Practice Address - Phone:260-495-2255
Practice Address - Fax:260-495-9023
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008007A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice