Provider Demographics
NPI:1821147190
Name:PARK, SUSAN (DDS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PARK
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 1:3850 N CAUSEWAY BLVD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-1752
Mailing Address - Country:US
Mailing Address - Phone:800-622-7645
Mailing Address - Fax:
Practice Address - Street 1:709 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-1669
Practice Address - Country:US
Practice Address - Phone:315-452-5915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048609-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics