Provider Demographics
NPI:1477614717
Name:LEARY, SUSAN (DDS)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:LEARY
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 1:276 B AVE
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-1975
Mailing Address - Country:US
Mailing Address - Phone:858-966-4094
Mailing Address - Fax:858-966-8097
Practice Address - Street 1:3020 CHILDREN'S WAY MC#5127
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4223
Practice Address - Country:US
Practice Address - Phone:858-966-4094
Practice Address - Fax:858-966-8097
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA536711223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD53671Medicaid