Provider Demographics
NPI:1821109950
Name:SULLIVAN, JOHN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
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 1:5136 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
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI126661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice