Provider Demographics
NPI:1235256082
Name:DEPATIE, SUSAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:DEPATIE
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 1:1340 BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119
Mailing Address - Country:US
Mailing Address - Phone:860-521-2500
Mailing Address - Fax:
Practice Address - Street 1:1340 BOULEVARD
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119
Practice Address - Country:US
Practice Address - Phone:860-521-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT64621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice