Provider Demographics
NPI:1073552873
Name:SULLIVAN, DENNIS MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:MICHAEL
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:D. MICHAEL
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:2305 SE WASHINGTON ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7647
Mailing Address - Country:US
Mailing Address - Phone:503-659-0064
Mailing Address - Fax:503-659-0445
Practice Address - Street 1:2305 SE WASHINGTON ST
Practice Address - Street 2:SUITE 109
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7647
Practice Address - Country:US
Practice Address - Phone:503-659-0064
Practice Address - Fax:503-659-0445
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27-2247111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000QGFTRMedicare UPIN