Provider Demographics
NPI:1528191657
Name:SUSANIN, PETER B (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:B
Last Name:SUSANIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 W LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:DEVON
Mailing Address - State:PA
Mailing Address - Zip Code:19333-1555
Mailing Address - Country:US
Mailing Address - Phone:610-687-0339
Mailing Address - Fax:
Practice Address - Street 1:227 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:DEVON
Practice Address - State:PA
Practice Address - Zip Code:19333-1555
Practice Address - Country:US
Practice Address - Phone:610-687-0339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025547L1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics