Provider Demographics
NPI:1629254859
Name:JOHN J SULLIVAN, DDS, PC
Entity Type:Organization
Organization Name:JOHN J SULLIVAN, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-367-4276
Mailing Address - Street 1:325 W WHITE MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929
Mailing Address - Country:US
Mailing Address - Phone:928-367-4276
Mailing Address - Fax:
Practice Address - Street 1:325 W WHITE MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929
Practice Address - Country:US
Practice Address - Phone:928-367-4276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2685122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty