1205984655 NPI number — DR. SUSAN AHLENE NORDSTROM DMD MS

Table of content: DR. SUSAN AHLENE NORDSTROM DMD MS (NPI 1205984655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205984655 NPI number — DR. SUSAN AHLENE NORDSTROM DMD MS

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GUENTZEL
Provider Other First Name:
SUSAN
Provider Other Middle Name:
AHLENE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205984655
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6950 NE CAMPUS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HILLSBORO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97124-5611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-952-2164
Provider Business Mailing Address Fax Number:
503-526-4418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 NE 82ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98665-8847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-546-0183
Provider Business Practice Location Address Fax Number:
360-546-0223
Provider Enumeration Date:
01/08/2007

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: 1223X0400X , with the licence number:  DE 00010334 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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