Provider Demographics
NPI:1760548713
Name:EZZATI, SUSAN (DDS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:EZZATI
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 1:881 FREMONT AVE STE B1
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-5637
Mailing Address - Country:US
Mailing Address - Phone:650-949-4734
Mailing Address - Fax:650-949-5710
Practice Address - Street 1:881 FREMONT AVE STE B1
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94024-5637
Practice Address - Country:US
Practice Address - Phone:650-949-4734
Practice Address - Fax:650-949-5710
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35491122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist