Healthcare Provider Details

I. General information

NPI: 1548192040
Provider Name (Legal Business Name): SUSEJ BANDRES DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 S ARCHER AVE
CHICAGO IL
60608-6837
US

IV. Provider business mailing address

355 N HALSTED ST APT 1910
CHICAGO IL
60661-2354
US

V. Phone/Fax

Practice location:
  • Phone: 872-314-1807
  • Fax:
Mailing address:
  • Phone: 407-965-7962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.037085
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: