Provider Demographics
NPI:1790158905
Name:JOHN M. SULLIVAN DDS, PLLC
Entity Type:Organization
Organization Name:JOHN M. SULLIVAN DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-742-6060
Mailing Address - Street 1:5136 DAVISON RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-1569
Mailing Address - Country:US
Mailing Address - Phone:810-742-6060
Mailing Address - Fax:810-742-3022
Practice Address - Street 1:5136 DAVISON RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1569
Practice Address - Country:US
Practice Address - Phone:810-742-6060
Practice Address - Fax:810-742-3022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901012666122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty