Provider Demographics
NPI:1245241728
Name:SULLIVAN, MICHAEL WARREN (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WARREN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12136 W 87TH ST PKWY
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66215-2893
Mailing Address - Country:US
Mailing Address - Phone:913-492-5052
Mailing Address - Fax:913-492-7039
Practice Address - Street 1:12136 W 87TH ST PKWY
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66215-2893
Practice Address - Country:US
Practice Address - Phone:913-492-5052
Practice Address - Fax:913-492-7039
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice