=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295266013
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUE MIN MAK DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2017
-----------------------------------------------------
Last Update Date | 08/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 725 RESERVOIR AVE STE 301B
-----------------------------------------------------
City | CRANSTON
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02910-4451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-415-0101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 679 WASHINGTON ST STE 3-314
-----------------------------------------------------
City | ATTLEBORO
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02703-8406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-501-9271
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN1857349
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------