Provider Demographics
NPI:1770638066
Name:SULLIVAN, KEVIN PATRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:PATRICK
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 1:305 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-3315
Mailing Address - Country:US
Mailing Address - Phone:509-962-9020
Mailing Address - Fax:509-925-9022
Practice Address - Street 1:305 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3315
Practice Address - Country:US
Practice Address - Phone:509-962-9020
Practice Address - Fax:509-925-9022
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA8766122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist