Provider Demographics
NPI:1104518968
Name:LAI, SUSAN (DMD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:LAI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12676 SW 133RD AVE
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-4714
Mailing Address - Country:US
Mailing Address - Phone:503-927-8086
Mailing Address - Fax:
Practice Address - Street 1:30040 SW BOONES FERRY RD STE 20
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-8910
Practice Address - Country:US
Practice Address - Phone:503-682-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORD11824122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program