Provider Demographics
NPI:1568540540
Name:ROUBICEK, SUSAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:ROUBICEK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 INDIAN LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE FERRY
Mailing Address - State:NJ
Mailing Address - Zip Code:07643
Mailing Address - Country:US
Mailing Address - Phone:201-794-4789
Mailing Address - Fax:
Practice Address - Street 1:739 WOODROW RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312
Practice Address - Country:US
Practice Address - Phone:718-317-8524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0442261223X0400X
NJDI171581223X0400X
MA180981223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics