Provider Demographics
NPI:1003986928
Name:SULLIVAN, LARRY D (DDS)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 HAZEL ST
Mailing Address - Street 2:
Mailing Address - City:WILLITS
Mailing Address - State:CA
Mailing Address - Zip Code:95490-4222
Mailing Address - Country:US
Mailing Address - Phone:707-456-9700
Mailing Address - Fax:707-456-9585
Practice Address - Street 1:45 HAZEL ST
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-4222
Practice Address - Country:US
Practice Address - Phone:707-456-9700
Practice Address - Fax:707-456-9585
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18646122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist