Provider Demographics
NPI:1104055235
Name:SU, PEITI (DDS)
Entity type:Individual
Prefix:
First Name:PEITI
Middle Name:
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 1:4300 BERRENDO DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95864-3120
Mailing Address - Country:US
Mailing Address - Phone:916-432-3431
Mailing Address - Fax:
Practice Address - Street 1:1721 LA PLAYA WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95864-1508
Practice Address - Country:US
Practice Address - Phone:916-432-3431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-10
Last Update Date:2013-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA620321223E0200X
NY055065-11223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics