Provider Demographics
NPI:1295464220
Name:O'SULLIVAN, ROBERT JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JOSEPH
Last Name:O'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 1:1000 GREG KRUSCHEK AVENUE
Mailing Address - Street 2:
Mailing Address - City:NOME
Mailing Address - State:AK
Mailing Address - Zip Code:99762-8754
Mailing Address - Country:US
Mailing Address - Phone:907-443-3311
Mailing Address - Fax:
Practice Address - Street 1:1000 GREG KRUSCHEK AVENUE
Practice Address - Street 2:
Practice Address - City:NOME
Practice Address - State:AK
Practice Address - Zip Code:99762
Practice Address - Country:US
Practice Address - Phone:907-443-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTDEN-DEN-LIC-236671223G0001X
WI6001012-151223G0001X
IL019.0336941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice