Provider Demographics
NPI:1467861799
Name:KANESHIRO, SUZANNE SISON (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:SISON
Last Name:KANESHIRO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:SUZANNE
Other - Middle Name:ARLENE
Other - Last Name:SISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:505 HARMON LOOP RD.
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DEDEDO
Mailing Address - State:GU
Mailing Address - Zip Code:96429
Mailing Address - Country:US
Mailing Address - Phone:671-637-9696
Mailing Address - Fax:671-632-6464
Practice Address - Street 1:505 HARMON LOOP RD.
Practice Address - Street 2:SUITE 300
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96929
Practice Address - Country:US
Practice Address - Phone:671-637-9696
Practice Address - Fax:671-637-6464
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-12
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUD9041223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice