Provider Demographics
NPI:1720381254
Name:ROBERTS, SUSAN ELIZABETH (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 S RENTON VILLAGE PL STE 786
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-3294
Mailing Address - Country:US
Mailing Address - Phone:425-996-7002
Mailing Address - Fax:
Practice Address - Street 1:555 S RENTON VILLAGE PL
Practice Address - Street 2:STE 786
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-3294
Practice Address - Country:US
Practice Address - Phone:425-207-8677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-05
Last Update Date:2010-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000102811223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics