Provider Demographics
NPI:1093931057
Name:SULLIVAN, TERENCE KEVIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:TERENCE
Middle Name:KEVIN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 HIGHLAND PARK PLZ
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-7129
Mailing Address - Country:US
Mailing Address - Phone:985-892-3310
Mailing Address - Fax:985-892-2578
Practice Address - Street 1:206 HIGHLAND PARK PLZ
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7129
Practice Address - Country:US
Practice Address - Phone:985-892-3310
Practice Address - Fax:985-892-2578
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA27641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1827649Medicaid