Provider Demographics
NPI:1467076034
Name:OSULLIVAN, CORNELIUS JOSEPH
Entity Type:Individual
Prefix:DR
First Name:CORNELIUS
Middle Name:JOSEPH
Last Name:OSULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 ERIE CLIFF DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-1214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13616 MADISON AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4709
Practice Address - Country:US
Practice Address - Phone:216-221-1438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-30
Last Update Date:2020-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0261591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice