Provider Demographics
NPI:1104992361
Name:SUSS, JASON M (DMD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:SUSS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1684 HANOVER ST
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-2222
Mailing Address - Country:US
Mailing Address - Phone:201-907-0099
Mailing Address - Fax:
Practice Address - Street 1:179 S PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621-2640
Practice Address - Country:US
Practice Address - Phone:201-384-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI02210300122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist