Provider Demographics
NPI:1437610821
Name:DEHBASHI, SUZAN
Entity Type:Individual
Prefix:
First Name:SUZAN
Middle Name:
Last Name:DEHBASHI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 BALES AVE
Mailing Address - Street 2:APT PH210
Mailing Address - City:TORONTO
Mailing Address - State:ON
Mailing Address - Zip Code:M2N7L6
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:324 ELMIRA RD STE 200
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5106
Practice Address - Country:US
Practice Address - Phone:213-400-1535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1045061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice