Provider Demographics
NPI:1689012403
Name:SULLIVAN, DANIEL JAMES (DMD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JAMES
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:PA
Mailing Address - Zip Code:18444-9020
Mailing Address - Country:US
Mailing Address - Phone:570-842-4255
Mailing Address - Fax:
Practice Address - Street 1:109 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:PA
Practice Address - Zip Code:18444-9020
Practice Address - Country:US
Practice Address - Phone:570-842-4255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-14
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0395471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice