Provider Demographics
NPI:1073644159
Name:SUSAT, JONATHAN C (DDS)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:C
Last Name:SUSAT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 NEW LONDON TPKE
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2237
Mailing Address - Country:US
Mailing Address - Phone:860-633-3671
Mailing Address - Fax:860-633-9128
Practice Address - Street 1:416 NEW LONDON TPKE
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2237
Practice Address - Country:US
Practice Address - Phone:860-633-3671
Practice Address - Fax:860-633-9128
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT58151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT020005815CT01OtherANTHEM BCBS
CT2058154Medicaid