Provider Demographics
NPI:1083912281
Name:SULLIVAN, MELISSA T (RDH)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:T
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67344 TROUT RD
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81403-8670
Mailing Address - Country:US
Mailing Address - Phone:970-249-5714
Mailing Address - Fax:
Practice Address - Street 1:67344 TROUT RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81403-8670
Practice Address - Country:US
Practice Address - Phone:970-249-5714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-11
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO201123124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist