Provider Demographics
NPI:1376660076
Name:LEIVA, SUSAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:LEIVA
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 1:2 CENTRE DR STE 300
Mailing Address - Street 2:
Mailing Address - City:MONROE TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-1564
Mailing Address - Country:US
Mailing Address - Phone:609-409-1700
Mailing Address - Fax:609-409-1702
Practice Address - Street 1:2 CENTRE DR STE 300
Practice Address - Street 2:
Practice Address - City:MONROE TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08831-1564
Practice Address - Country:US
Practice Address - Phone:609-409-1700
Practice Address - Fax:609-409-1702
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ170001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics