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General NPI Number Information
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NPI Number | 1821147190
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Entity Type | Individual
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Provider Name | SUSAN PARK DDS
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Gender | Female
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Dates
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Enumeration Date | 01/09/2007
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Last Update Date | 08/24/2010
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Provider Practice Location Address
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Address Line | 709 N MAIN ST
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City | NORTH SYRACUSE
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State | NY
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Zip | 13212-1669
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Country | US
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Telephone | 315-452-5915
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Fax |
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Provider Business Mailing Address
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Address Line | 3850 N CAUSEWAY BLVD SUITE 800
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City | METAIRIE
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State | LA
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Zip | 70002-1752
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Country | US
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Telephone | 800-622-7645
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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 | 048609-1
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License Number State | NY
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