Provider Demographics
NPI:1568586386
Name:BORDENAVE-BISHOP, SUSAN B (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:B
Last Name:BORDENAVE-BISHOP
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 1:7314 N. EDGEWILD DR.
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-692-1796
Mailing Address - Fax:309-679-6139
Practice Address - Street 1:2116 N. SHERIDAN
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604
Practice Address - Country:US
Practice Address - Phone:309-679-6140
Practice Address - Fax:309-679-6139
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice