Provider Demographics
NPI:1689088056
Name:MICHAEL J. SULLIVAN, D.D.S., INC
Entity Type:Organization
Organization Name:MICHAEL J. SULLIVAN, D.D.S., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-761-9393
Mailing Address - Street 1:1882 HARD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-1996
Mailing Address - Country:US
Mailing Address - Phone:614-761-9393
Mailing Address - Fax:617-761-9363
Practice Address - Street 1:1882 HARD RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-1996
Practice Address - Country:US
Practice Address - Phone:614-761-9393
Practice Address - Fax:617-761-9363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.016980122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1154672038OtherNPI
OH0469265Medicaid