Individual
MELISA SUSANTO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DDS
Contact information
Practice address
16810 MERIDIAN E, SUITE J104, PUYALLUP, WA 98375-9604
(626) 241-2669
Mailing address
16810 MERIDIAN E, SUITE J104, PUYALLUP, WA 98375-9604
(626) 241-2669
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
2901020349
MI
1223P0221X
Pediatric Dentistry
Primary
DE60481607
WA
Other
Enumeration date
03/28/2011
Last updated
07/28/2014
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