Provider Demographics
NPI:1790857886
Name:EDUKUTHARAYIL, SUSAN (DDS)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:EDUKUTHARAYIL
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 1:2124 SCHUMACHER DR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-0966
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 S GROVE AVE
Practice Address - Street 2:STE 204
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-6430
Practice Address - Country:US
Practice Address - Phone:847-608-1122
Practice Address - Fax:847-608-1133
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice