Provider Demographics
NPI:1619949377
Name:SULLIVAN, BARRY (DDS)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:
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 1:4009 N FLOWING WELLS RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705-2404
Mailing Address - Country:US
Mailing Address - Phone:520-408-0836
Mailing Address - Fax:520-293-2964
Practice Address - Street 1:4009 N FLOWING WELLS RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-2404
Practice Address - Country:US
Practice Address - Phone:520-408-0836
Practice Address - Fax:520-293-2964
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ56071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ695926Medicaid