Provider Demographics
NPI:1720007776
Name:SULLA, MAXIM (DDS)
Entity Type:Individual
Prefix:
First Name:MAXIM
Middle Name:
Last Name:SULLA
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 1:1313 STATE ROUTE 27
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-3439
Mailing Address - Country:US
Mailing Address - Phone:732-249-1010
Mailing Address - Fax:732-220-0177
Practice Address - Street 1:1313 STATE ROUTE 27
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-3439
Practice Address - Country:US
Practice Address - Phone:732-249-1010
Practice Address - Fax:732-220-0177
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI212051223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry