Provider Demographics
NPI:1619035896
Name:COCQUYT, SUSAN MARIE (DDS)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:COCQUYT
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 1:734 E IRELAND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-2662
Mailing Address - Country:US
Mailing Address - Phone:574-299-9300
Mailing Address - Fax:
Practice Address - Street 1:734 E IRELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2662
Practice Address - Country:US
Practice Address - Phone:574-299-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009553122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist