Provider Demographics
NPI:1861642092
Name:ELLISON, SUSAN (DDS)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:ELLISON
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 1:12850 JONES RD STE 103
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-4956
Mailing Address - Country:US
Mailing Address - Phone:281-890-2828
Mailing Address - Fax:281-897-9793
Practice Address - Street 1:12850 JONES RD STE 103
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-4956
Practice Address - Country:US
Practice Address - Phone:281-890-2828
Practice Address - Fax:281-897-9793
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15975122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist