Provider Demographics
NPI:1295711844
Name:WHEELER MOLSTAD, SUSAN L (DDS)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:L
Last Name:WHEELER MOLSTAD
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 1:814 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:ELLIS
Mailing Address - State:KS
Mailing Address - Zip Code:67637-2215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:814 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ELLIS
Practice Address - State:KS
Practice Address - Zip Code:67637-2215
Practice Address - Country:US
Practice Address - Phone:785-726-3557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS65151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS4054858601Medicaid
KS100223820-AOtherDORAL PROVIDER NUMBER