Provider Demographics
NPI:1598873580
Name:SULLIVAN DENTAL CENTER
Entity Type:Organization
Organization Name:SULLIVAN DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LILLIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-635-4422
Mailing Address - Street 1:PO BOX 2880
Mailing Address - Street 2:
Mailing Address - City:ST FRANCISVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70775
Mailing Address - Country:US
Mailing Address - Phone:225-635-4422
Mailing Address - Fax:225-635-2171
Practice Address - Street 1:5436 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:ST FRANCISVILLE
Practice Address - State:LA
Practice Address - Zip Code:70775
Practice Address - Country:US
Practice Address - Phone:225-635-4422
Practice Address - Fax:225-241-7155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5062122300000X
LA5558122300000X
LA49881223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty