Provider Demographics
NPI:1598759789
Name:SULLIVAN, ELLEN J (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21414 SPENCER AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-1821
Mailing Address - Country:US
Mailing Address - Phone:718-468-1812
Mailing Address - Fax:718-468-1815
Practice Address - Street 1:21414 SPENCER AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-1821
Practice Address - Country:US
Practice Address - Phone:718-468-1812
Practice Address - Fax:718-468-1815
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-02
Last Update Date:2007-07-08
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
NY0368231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice