Provider Demographics
NPI:1619435682
Name:O'SULLIVAN, MAUREEN (ADT)
Entity Type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:
Last Name:O'SULLIVAN
Suffix:
Gender:F
Credentials:ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 S OWASSO BLVD W
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2119
Mailing Address - Country:US
Mailing Address - Phone:612-801-5203
Mailing Address - Fax:
Practice Address - Street 1:385 S OWASSO BLVD W
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-2119
Practice Address - Country:US
Practice Address - Phone:612-801-5203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-07
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH9759124Q00000X
MNDT83125K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125K00000XDental ProvidersAdvanced Practice Dental Therapist
No124Q00000XDental ProvidersDental Hygienist