Provider Demographics
NPI:1326116773
Name:DIBENE, SUSAN R (DDS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:DIBENE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6541 CROWN BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120-2907
Mailing Address - Country:US
Mailing Address - Phone:408-268-8420
Mailing Address - Fax:
Practice Address - Street 1:6541 CROWN BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95120-2907
Practice Address - Country:US
Practice Address - Phone:408-268-8420
Practice Address - Fax:408-268-8439
Is Sole Proprietor?:No
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA397861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice