Provider Demographics
NPI:1063683472
Name:TULLOS, STEPHANIE SULLIVAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:SULLIVAN
Last Name:TULLOS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:MS
Mailing Address - Zip Code:39153-6016
Mailing Address - Country:US
Mailing Address - Phone:601-782-9909
Mailing Address - Fax:601-782-9133
Practice Address - Street 1:276 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:MS
Practice Address - Zip Code:39153-6016
Practice Address - Country:US
Practice Address - Phone:601-782-9909
Practice Address - Fax:601-782-9133
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3265-03122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00077253Medicaid