Provider Demographics
NPI:1083955603
Name:KIA, SUZANNA (DMD)
Entity Type:Individual
Prefix:
First Name:SUZANNA
Middle Name:
Last Name:KIA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 CHASE AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06704-2245
Mailing Address - Country:US
Mailing Address - Phone:203-754-3818
Mailing Address - Fax:
Practice Address - Street 1:188 CHASE AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06704-2245
Practice Address - Country:US
Practice Address - Phone:203-754-3818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT113611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice