Provider Demographics
NPI:1386037562
Name:SULLIVAN, PAUL (DDS)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
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 1:421 N 38TH ST
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-4153
Mailing Address - Country:US
Mailing Address - Phone:254-634-0234
Mailing Address - Fax:254-634-5307
Practice Address - Street 1:421 N 38TH ST
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-4153
Practice Address - Country:US
Practice Address - Phone:254-634-0234
Practice Address - Fax:254-634-5307
Is Sole Proprietor?:No
Enumeration Date:2015-03-11
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX230381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice