1467494427 NPI number — DR. SUSAN GAIL COTTRELL DMD

Table of content: DR. SUSAN GAIL COTTRELL DMD (NPI 1467494427)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467494427 NPI number — DR. SUSAN GAIL COTTRELL DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COTTRELL
Provider First Name:
SUSAN
Provider Middle Name:
GAIL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KELLY
Provider Other First Name:
SUSAN
Provider Other Middle Name:
COTTRELL
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467494427
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3799 E CR 30A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ROSA BCH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-586-2043
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
LECOM
Provider Second Line Business Practice Location Address:
101 LECOM WAY
Provider Business Practice Location Address City Name:
DEFUNIAK SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-951-0200
Provider Business Practice Location Address Fax Number:
850-951-6706
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN 13050 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110327000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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