=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932349990
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN LEE OH D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2009
-----------------------------------------------------
Last Update Date | 12/25/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 JUANA AVE STE 102
-----------------------------------------------------
City | SAN LEANDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94577-4841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-483-2670
-----------------------------------------------------
Fax | 510-483-1566
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 250 JUANA AVE STE 102
-----------------------------------------------------
City | SAN LEANDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94577-4841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-483-2670
-----------------------------------------------------
Fax | 510-483-1566
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 57905
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------