Provider Demographics
NPI:1366720013
Name:MIKLOS, SUSAN M (EFDA,RDH, BSDH, MSDH)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:M
Last Name:MIKLOS
Suffix:
Gender:F
Credentials:EFDA,RDH, BSDH, MSDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 SQUIRES RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-1792
Mailing Address - Country:US
Mailing Address - Phone:203-915-1666
Mailing Address - Fax:
Practice Address - Street 1:126 PARK AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-7620
Practice Address - Country:US
Practice Address - Phone:203-576-4823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006553124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist