Provider Demographics
NPI:1396044517
Name:SUSANTO, MELISA (DDS)
Entity Type:Individual
Prefix:
First Name:MELISA
Middle Name:
Last Name:SUSANTO
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 1:16810 MERIDIAN E
Mailing Address - Street 2:SUITE J104
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-9604
Mailing Address - Country:US
Mailing Address - Phone:626-241-2669
Mailing Address - Fax:
Practice Address - Street 1:16810 MERIDIAN E
Practice Address - Street 2:SUITE J104
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-9604
Practice Address - Country:US
Practice Address - Phone:626-241-2669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010203491223G0001X
WADE604816071223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice