Provider Demographics
NPI:1356681654
Name:SULLIVAN, JENNIFER CHANG (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:CHANG
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 BEDFORD ST STE 20
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-4440
Mailing Address - Country:US
Mailing Address - Phone:617-468-8696
Mailing Address - Fax:
Practice Address - Street 1:35 BEDFORD ST STE 20
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-4440
Practice Address - Country:US
Practice Address - Phone:617-468-8696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-22
Last Update Date:2023-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNS1251223P0300X
TX263731223P0300X
MA18598581223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodontics