Provider Demographics
NPI:1598019325
Name:SULLIVAN, STACY LYNN (DDS, MS)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:LYNN
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS, MS
Mailing Address - Street 1:450 OAK AVE
Mailing Address - Street 2:UNIT 303
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-1389
Mailing Address - Country:US
Mailing Address - Phone:734-945-7435
Mailing Address - Fax:
Practice Address - Street 1:36600 HERITAGE DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MI
Practice Address - Zip Code:48062-1937
Practice Address - Country:US
Practice Address - Phone:586-727-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010211561223P0221X
IL319.0182881223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry