Provider Demographics
NPI:1508082835
Name:SULLIVAN, JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
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 1:517 LEWIS AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-1002
Mailing Address - Country:US
Mailing Address - Phone:228-432-5222
Mailing Address - Fax:228-432-5223
Practice Address - Street 1:1025 DIVISION ST
Practice Address - Street 2:SUITE F
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530-2906
Practice Address - Country:US
Practice Address - Phone:228-432-5222
Practice Address - Fax:228-432-5223
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1701122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist