Provider Demographics
NPI:1649276155
Name:SU, ROBIN MARGUERITE (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBIN
Middle Name:MARGUERITE
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 1:440 N MOUNTAIN AVE
Mailing Address - Street 2:STE 116
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-5183
Mailing Address - Country:US
Mailing Address - Phone:909-985-3430
Mailing Address - Fax:909-985-1936
Practice Address - Street 1:440 N MOUNTAIN AVE
Practice Address - Street 2:STE 116
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5183
Practice Address - Country:US
Practice Address - Phone:909-985-3430
Practice Address - Fax:909-985-1936
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
CA36115122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1510728OtherUNITED CONCORDIA PROVIDER