Provider Demographics
NPI:1316082464
Name:SUSU, THEODORE SEYENA (DDS)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:SEYENA
Last Name:SUSU
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 DUTCHESS TPKE STE 104
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-6443
Mailing Address - Country:US
Mailing Address - Phone:845-471-8855
Mailing Address - Fax:845-471-8270
Practice Address - Street 1:695 DUTCHESS TURNPIKE STE. 104
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603
Practice Address - Country:US
Practice Address - Phone:845-471-8855
Practice Address - Fax:845-471-8270
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050398122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist