Provider Demographics
NPI:1073524419
Name:SULLIVAN, MARTHA M (GENERAL DENTISTRY)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:GENERAL DENTISTRY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 QUEEN ST
Mailing Address - Street 2:DENTAL
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-2473
Mailing Address - Country:US
Mailing Address - Phone:508-860-7700
Mailing Address - Fax:508-860-7990
Practice Address - Street 1:26 QUEEN ST
Practice Address - Street 2:DENTAL
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2473
Practice Address - Country:US
Practice Address - Phone:508-860-7700
Practice Address - Fax:508-860-7990
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15920122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA15920OtherANTHEM BCBS DENTAL
MA15920OtherGUARDIAN DENTAL
MA1300709Medicaid
MA91285OtherFALLON SELECT
MA15920OtherAMERITAS
MA15920OtherANTHEM BLUECARE
MA15920OtherALTUS DENTAL
MAAA20303OtherHARVARD PILGRIM
MA15920OtherANTHEM BCBS DENTAL