Provider Demographics
NPI:1033566344
Name:SULLIVAN, KAITLIN ANNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KAITLIN
Middle Name:ANNE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8559 EDINBROOK PKWY
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55443-3747
Mailing Address - Country:US
Mailing Address - Phone:763-425-3644
Mailing Address - Fax:
Practice Address - Street 1:8559 EDINBROOK PKWY
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55443-3747
Practice Address - Country:US
Practice Address - Phone:763-425-3644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13657122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist