Provider Demographics
NPI:1639586258
Name:SULLIVAN, MICHAEL R (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
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 1:3101 TREASURE HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-8668
Mailing Address - Country:US
Mailing Address - Phone:940-210-2810
Mailing Address - Fax:
Practice Address - Street 1:2106 TREASURE HILLS BLVD
Practice Address - Street 2:VA TEXAS VALLEY COASTAL BEND HEALTH CARE
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-8736
Practice Address - Country:US
Practice Address - Phone:940-210-2810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX301171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice