Provider Demographics
NPI:1679624902
Name:REAL-RAZ, SUSAN R (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:R
Last Name:REAL-RAZ
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 1:12725 PERRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-4110
Mailing Address - Country:US
Mailing Address - Phone:951-486-0119
Mailing Address - Fax:951-486-9143
Practice Address - Street 1:12725 PERRIS BLVD
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-4110
Practice Address - Country:US
Practice Address - Phone:951-486-0119
Practice Address - Fax:951-486-9143
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA424021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice