Provider Demographics
NPI:1639403629
Name:SULLIVAN, NALA S (DDS)
Entity Type:Individual
Prefix:DR
First Name:NALA
Middle Name:S
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 1:12800 FOUNTAIN LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477
Mailing Address - Country:US
Mailing Address - Phone:281-277-1659
Mailing Address - Fax:281-277-1236
Practice Address - Street 1:12800 FOUNTAIN LAKE CIR
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-3756
Practice Address - Country:US
Practice Address - Phone:281-277-1659
Practice Address - Fax:281-277-1236
Is Sole Proprietor?:No
Enumeration Date:2009-09-24
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX258071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice