Provider Demographics
NPI:1053318048
Name:CHADKEWICZ, SUSAN VIVIEN B (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN VIVIEN
Middle Name:B
Last Name:CHADKEWICZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:S VIVIEN
Other - Middle Name:B
Other - Last Name:CHADKEWICZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:16466 BERNARDO CENTER DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2508
Mailing Address - Country:US
Mailing Address - Phone:858-673-0552
Mailing Address - Fax:858-673-2045
Practice Address - Street 1:16466 BERNARDO CENTER DR
Practice Address - Street 2:SUITE 150
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2508
Practice Address - Country:US
Practice Address - Phone:858-673-0552
Practice Address - Fax:858-673-2045
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
CA490701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice