Provider Demographics
NPI:1184709487
Name:SU, DENNIS (DMD)
Entity type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:
Last Name:SU
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 MARIN PRIVADO
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764
Mailing Address - Country:US
Mailing Address - Phone:909-896-1880
Mailing Address - Fax:
Practice Address - Street 1:572 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148
Practice Address - Country:US
Practice Address - Phone:781-397-8876
Practice Address - Fax:781-324-7166
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21440122300000X
CA556881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist