Provider Demographics
NPI:1689649386
Name:SUSHOREBA, DUANE MATHEW (DDS)
Entity Type:Individual
Prefix:
First Name:DUANE
Middle Name:MATHEW
Last Name:SUSHOREBA
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 1:20 5TH ST SE
Mailing Address - Street 2:DENTAL
Mailing Address - City:COOK
Mailing Address - State:MN
Mailing Address - Zip Code:55723-9702
Mailing Address - Country:US
Mailing Address - Phone:218-666-5958
Mailing Address - Fax:218-666-5099
Practice Address - Street 1:20 5TH ST SE
Practice Address - Street 2:
Practice Address - City:COOK
Practice Address - State:MN
Practice Address - Zip Code:55723-9702
Practice Address - Country:US
Practice Address - Phone:218-666-5958
Practice Address - Fax:218-666-5099
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND88611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice