Provider Demographics
NPI:1871510552
Name:RESTIC, SUSAN SCHAUMBURG (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:SCHAUMBURG
Last Name:RESTIC
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:ANNETTE
Other - Last Name:SCHAUMBURG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:4350 LAKEVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5555
Mailing Address - Country:US
Mailing Address - Phone:503-675-1398
Mailing Address - Fax:
Practice Address - Street 1:10209 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9782
Practice Address - Country:US
Practice Address - Phone:503-353-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD67291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice