Provider Demographics
NPI:1295393114
Name:SULLIVAN, REANNA LEIGH
Entity Type:Individual
Prefix:
First Name:REANNA
Middle Name:LEIGH
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 CENTRAL PARK DR STE 101
Mailing Address - Street 2:
Mailing Address - City:STEAMBOAT SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80487-8853
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 MAIN ST.
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:CO
Practice Address - Zip Code:80467
Practice Address - Country:US
Practice Address - Phone:970-824-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO105925020122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist