Basic Information
| Provider Information | |||||||||
| NPI: | 1417035569 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RADIVOJEVIC | ||||||||
| FirstName: | SUSANNE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KHAN | ||||||||
| OtherFirstName: | TIPO | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DDS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1945 W WILSON AVE | ||||||||
| Address2: | SUITE 5106 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606405255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732758855 | ||||||||
| FaxNumber: | 7732758822 | ||||||||
| Practice Location | |||||||||
| Address1: | 1945 W WILSON AVE | ||||||||
| Address2: | SUITE 5106 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606405255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732758855 | ||||||||
| FaxNumber: | 7732758822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | IL | Y | Dental Providers | Dentist | General Practice |
No ID Information.