Provider Demographics
NPI:1649409632
Name:SULLIVAN, LAURA GRACE (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:GRACE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:GRACE
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1949 CR 210 W
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259
Mailing Address - Country:US
Mailing Address - Phone:904-808-4700
Mailing Address - Fax:904-342-8113
Practice Address - Street 1:1949 CR 210 W
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-2062
Practice Address - Country:US
Practice Address - Phone:904-402-4409
Practice Address - Fax:904-342-8113
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18660122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist