Provider Demographics
NPI:1568486462
Name:SULLIVAN, STUART RANDALL (DDS)
Entity Type:Individual
Prefix:DR
First Name:STUART
Middle Name:RANDALL
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 1:6135 E HARRY ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-3827
Mailing Address - Country:US
Mailing Address - Phone:316-684-1771
Mailing Address - Fax:
Practice Address - Street 1:6135 E HARRY ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-3827
Practice Address - Country:US
Practice Address - Phone:316-684-1771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS64621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice