Provider Demographics
NPI:1689006520
Name:SULLIVAN, MARK PHILIP (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:PHILIP
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 1:6545 FRANCE AVE S STE 366
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2121
Mailing Address - Country:US
Mailing Address - Phone:952-241-5851
Mailing Address - Fax:
Practice Address - Street 1:6545 FRANCE AVE S STE 366
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2121
Practice Address - Country:US
Practice Address - Phone:952-241-5851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND135011223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics