Provider Demographics
NPI:1417035569
Name:RADIVOJEVIC, SUSANNE S (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSANNE
Middle Name:S
Last Name:RADIVOJEVIC
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:TIPO
Other - Middle Name:A
Other - Last Name:KHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1945 W WILSON AVE
Mailing Address - Street 2:SUITE 5106
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5255
Mailing Address - Country:US
Mailing Address - Phone:773-275-8855
Mailing Address - Fax:773-275-8822
Practice Address - Street 1:1945 W WILSON AVE
Practice Address - Street 2:SUITE 5106
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5255
Practice Address - Country:US
Practice Address - Phone:773-275-8855
Practice Address - Fax:773-275-8822
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice