Provider Demographics
NPI:1669466280
Name:SULLIVAN, COLEEN (DDS)
Entity Type:Individual
Prefix:
First Name:COLEEN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:COLEEN
Other - Middle Name:
Other - Last Name:BARRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:400 HUALANI ST
Mailing Address - Street 2:BLDG 9 SUITE 192
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-4378
Mailing Address - Country:US
Mailing Address - Phone:808-935-6620
Mailing Address - Fax:808-523-3121
Practice Address - Street 1:400 HUALANI ST
Practice Address - Street 2:BLDG 9 SUITE 192
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-4378
Practice Address - Country:US
Practice Address - Phone:808-935-6620
Practice Address - Fax:808-935-6781
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ45031223G0001X
HIDT-25961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ191958Medicaid