Healthcare Provider Details

I. General information

NPI: 1427063973
Provider Name (Legal Business Name): SUSAN CAROLYN BESTGEN D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S HUNTINGTON AVE DENTAL SERVICE (160)
JAMAICA PLAIN MA
02130-4817
US

IV. Provider business mailing address

57 COTTAGE RD
WEST ROXBURY MA
02132-5606
US

V. Phone/Fax

Practice location:
  • Phone: 617-232-9500
  • Fax: 857-364-2040
Mailing address:
  • Phone: 617-325-0332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number18312
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS-026019
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: