Provider Demographics
NPI:1922289982
Name:DE MATA, SUSAN TUNQUE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:TUNQUE
Last Name:DE MATA
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 1:18516 DEVLIN AVE
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90701-5730
Mailing Address - Country:US
Mailing Address - Phone:562-860-6421
Mailing Address - Fax:562-424-9848
Practice Address - Street 1:18516 DEVLIN AVE
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-5730
Practice Address - Country:US
Practice Address - Phone:562-860-6421
Practice Address - Fax:562-424-9848
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA565821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice