Provider Demographics
NPI:1134495096
Name:RO, SUSIE (SUSIE CHAN DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSIE
Middle Name:
Last Name:RO
Suffix:
Gender:F
Credentials:SUSIE CHAN DDS
Other - Prefix:DR
Other - First Name:SUSIE
Other - Middle Name:
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SUSIE CHAN DDS
Mailing Address - Street 1:17173 RALPHS RANCH RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-7825
Mailing Address - Country:US
Mailing Address - Phone:714-421-0430
Mailing Address - Fax:
Practice Address - Street 1:17173 RALPHS RANCH RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-7825
Practice Address - Country:US
Practice Address - Phone:714-421-0430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA577431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice