Provider Demographics
NPI:1669961173
Name:SUSARREY, AZIZ ROMAN (DMD)
Entity type:Individual
Prefix:
First Name:AZIZ
Middle Name:ROMAN
Last Name:SUSARREY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N CLARK ST FL 6
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-4712
Mailing Address - Country:US
Mailing Address - Phone:312-274-4524
Mailing Address - Fax:
Practice Address - Street 1:7345 W 25TH ST
Practice Address - Street 2:
Practice Address - City:NORTH RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-1409
Practice Address - Country:US
Practice Address - Phone:708-447-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0321691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice