Provider Demographics
NPI:1467697714
Name:ROSHAN, SUSAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:ROSHAN
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 1:5437 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75223-1914
Mailing Address - Country:US
Mailing Address - Phone:214-821-4726
Mailing Address - Fax:214-821-8403
Practice Address - Street 1:5437 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75223-1914
Practice Address - Country:US
Practice Address - Phone:214-821-4726
Practice Address - Fax:214-821-8403
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-15
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA53491223G0001X
TX230181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX344998501Medicaid