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General NPI Number Information
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NPI Number | 1568540540
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Entity Type | Individual
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Provider Name | SUSAN ROUBICEK DMD
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Gender | Female
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 739 WOODROW RD
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City | STATEN ISLAND
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State | NY
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Zip | 10312
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Country | US
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Telephone | 718-317-8524
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Fax |
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Provider Business Mailing Address
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Address Line | 21 INDIAN LAKE DRIVE
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City | LITTLE FERRY
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State | NJ
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Zip | 07643
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Country | US
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Telephone | 201-794-4789
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 044226
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DI17158
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License Number State | NJ
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Taxonomy #3
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 18098
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License Number State | MA
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