Provider Demographics
NPI:1215445101
Name:JO, SUSAN (DDS)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:JO
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 1:58 FRANCES CIR
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-5001
Mailing Address - Country:US
Mailing Address - Phone:714-269-4480
Mailing Address - Fax:
Practice Address - Street 1:11702 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:CA
Practice Address - Zip Code:90680-3609
Practice Address - Country:US
Practice Address - Phone:714-898-8552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-14
Last Update Date:2018-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1020651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice