Provider Demographics
NPI:1689849440
Name:TAKEMOTO, SUSAN A (DDS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:TAKEMOTO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4840 RIVERBEND RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2608
Mailing Address - Country:US
Mailing Address - Phone:303-440-4777
Mailing Address - Fax:303-440-4776
Practice Address - Street 1:4840 RIVERBEND RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2608
Practice Address - Country:US
Practice Address - Phone:303-440-4777
Practice Address - Fax:303-440-4776
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1051031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice