Provider Demographics
NPI:1497770853
Name:SULLIVAN, DENNIS J (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:BRIDGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04009
Mailing Address - Country:US
Mailing Address - Phone:207-647-3633
Mailing Address - Fax:207-647-5633
Practice Address - Street 1:55 MAIN ST.
Practice Address - Street 2:SUITE 2
Practice Address - City:BRIDGTON
Practice Address - State:ME
Practice Address - Zip Code:04009
Practice Address - Country:US
Practice Address - Phone:207-647-3633
Practice Address - Fax:207-647-5633
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME011964207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME105900000Medicaid
MEC66170Medicare UPIN
ME105900000Medicaid