Provider Demographics
NPI:1013070317
Name:SU, JOLYN (DDS)
Entity Type:Individual
Prefix:
First Name:JOLYN
Middle Name:
Last Name:SU
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 1:1426 112TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3710
Mailing Address - Country:US
Mailing Address - Phone:425-455-2370
Mailing Address - Fax:425-455-8509
Practice Address - Street 1:1426 112TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3710
Practice Address - Country:US
Practice Address - Phone:425-455-2370
Practice Address - Fax:425-455-8509
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010326122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist