Provider Demographics
NPI:1679703425
Name:SULLIVAN, JOHN MICHAEL (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9770 OLD BAYMEADOWS RD STE 113
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7986
Mailing Address - Country:US
Mailing Address - Phone:904-636-8999
Mailing Address - Fax:904-998-7804
Practice Address - Street 1:9770 OLD BAYMEADOWS RD STE 113
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7986
Practice Address - Country:US
Practice Address - Phone:904-636-8999
Practice Address - Fax:904-998-7804
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18659122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist