Provider Demographics
NPI:1780375717
Name:DIBENEDETTO, SUZANNE (LDO)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:DIBENEDETTO
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 BLACK HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-4115
Mailing Address - Country:US
Mailing Address - Phone:609-415-6350
Mailing Address - Fax:609-484-8702
Practice Address - Street 1:6801 BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-4115
Practice Address - Country:US
Practice Address - Phone:609-415-6350
Practice Address - Fax:609-484-8702
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3875156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician