Provider Demographics
NPI:1669595674
Name:AJIMINE, SUSAN KAY (DDS)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:KAY
Last Name:AJIMINE
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:PO BOX 7000
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-7299
Mailing Address - Country:US
Mailing Address - Phone:707-465-1000
Mailing Address - Fax:
Practice Address - Street 1:5901 LAKE EARL DRIVE
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531
Practice Address - Country:US
Practice Address - Phone:707-465-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31189122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist