Provider Demographics
NPI:1457647083
Name:SULLIVAN, MICHAEL PATRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PATRICK
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 1:1008 G SREET
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NE
Mailing Address - Zip Code:68361
Mailing Address - Country:US
Mailing Address - Phone:402-759-4288
Mailing Address - Fax:402-759-4470
Practice Address - Street 1:1008 G SREET
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NE
Practice Address - Zip Code:68361
Practice Address - Country:US
Practice Address - Phone:402-759-4288
Practice Address - Fax:402-759-4470
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6938122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist