Provider Demographics
NPI:1063626976
Name:SUSANTO, PAULINE H (DDS)
Entity type:Individual
Prefix:DR
First Name:PAULINE
Middle Name:H
Last Name:SUSANTO
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 1:2555 OCEAN AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94132-1645
Mailing Address - Country:US
Mailing Address - Phone:415-337-9009
Mailing Address - Fax:844-273-9010
Practice Address - Street 1:2555 OCEAN AVE STE 204
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94132-1645
Practice Address - Country:US
Practice Address - Phone:415-337-9009
Practice Address - Fax:844-273-9010
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27562122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist