Provider Demographics
NPI:1720392517
Name:SULLIVAN, CARLA FLEMMING (DMD)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:FLEMMING
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3124 E 71ST ST
Mailing Address - Street 2:STE 100
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-5626
Mailing Address - Country:US
Mailing Address - Phone:918-496-1358
Mailing Address - Fax:918-496-1359
Practice Address - Street 1:3124 E 71ST ST
Practice Address - Street 2:STE 100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-5626
Practice Address - Country:US
Practice Address - Phone:918-496-1358
Practice Address - Fax:918-496-1359
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-04
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK62331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice