Provider Demographics
NPI:1023203486
Name:PARK, SUSAN MA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MA
Last Name:PARK
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 1:9444 SE 52ND ST
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-4724
Mailing Address - Country:US
Mailing Address - Phone:206-883-6720
Mailing Address - Fax:
Practice Address - Street 1:1600 148TH AVE SE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-6852
Practice Address - Country:US
Practice Address - Phone:425-747-3080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE7538122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADE7538OtherWA STATE