Provider Demographics
NPI:1083697742
Name:SULLIVAN, JERRY L (DDS PC)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 REELFOOT AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261
Mailing Address - Country:US
Mailing Address - Phone:731-885-2277
Mailing Address - Fax:731-885-8852
Practice Address - Street 1:1007 REELFOOT AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261
Practice Address - Country:US
Practice Address - Phone:731-885-2277
Practice Address - Fax:731-885-8852
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-26
Last Update Date:2024-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS1777122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist