Provider Demographics
NPI:1508945692
Name:SULLIVAN, MARY LINDA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LINDA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MARY LINDA
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1106 HACKBERRY LN
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-3115
Mailing Address - Country:US
Mailing Address - Phone:205-758-8872
Mailing Address - Fax:205-758-8272
Practice Address - Street 1:1106 HACKBERRY LN
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-3115
Practice Address - Country:US
Practice Address - Phone:205-758-8872
Practice Address - Fax:205-758-8272
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL47421223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics