Provider Demographics
NPI:1295002129
Name:SULLIVAN, MARILEE J (RDH/EPDH)
Entity Type:Individual
Prefix:
First Name:MARILEE
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RDH/EPDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:OR
Mailing Address - Zip Code:97002-0034
Mailing Address - Country:US
Mailing Address - Phone:503-678-2860
Mailing Address - Fax:
Practice Address - Street 1:21186 SAYRE DRIVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:OR
Practice Address - Zip Code:97002
Practice Address - Country:US
Practice Address - Phone:503-984-2860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH0550124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist