Provider Demographics
NPI:1386679157
Name:SULLIVAN, DAVID M (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:WAREHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02571-2093
Mailing Address - Country:US
Mailing Address - Phone:508-273-0110
Mailing Address - Fax:508-273-0112
Practice Address - Street 1:40 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:WAREHAM
Practice Address - State:MA
Practice Address - Zip Code:02571-2093
Practice Address - Country:US
Practice Address - Phone:508-273-0110
Practice Address - Fax:508-273-0112
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA195231223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI05029OtherDELTA DENTAL
PA1364146OtherUNITED CONCORDIA
IA70408OtherASSURANT EMPLOYEE BENEFIT
RICB870OtherBLUECROSS BLUESHIELD
MAX12120OtherBLUECROSS BLUESHIELD
ID70408OtherFORTIS
CA77777OtherDELTA DENTAL
MA04614OtherDELTA DENTAL
TX65978OtherMETLIFE
TN62308OtherCIGNA
WA64246OtherGUARDIAN
RI50503OtherALTUS
CADDPFSOtherDELTA DENTAL FEDERAL
NJ22189OtherDELTA DENTAL
ALCBAL1OtherBLUECROSS BLUESHIELD
KY60054OtherAETNA
MICDMIOOtherDELTA DENTAL