Provider Demographics
NPI:1407056112
Name:SULLIVAN, MARK ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBERT
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 1:55191 SHELBY RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-1150
Mailing Address - Country:US
Mailing Address - Phone:586-797-9118
Mailing Address - Fax:586-797-9085
Practice Address - Street 1:54951 MOUND RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-6028
Practice Address - Country:US
Practice Address - Phone:586-797-9118
Practice Address - Fax:586-797-9085
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI123431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4062594Medicaid