Provider Demographics
NPI:1851461347
Name:MARK R SULLIVAN DDS
Entity Type:Organization
Organization Name:MARK R SULLIVAN DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-797-9118
Mailing Address - Street 1:54951 MOUND ROAD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-6028
Mailing Address - Country:US
Mailing Address - Phone:586-797-9118
Mailing Address - Fax:586-797-9085
Practice Address - Street 1:54951 MOUND ROAD
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48316-6028
Practice Address - Country:US
Practice Address - Phone:586-797-9118
Practice Address - Fax:586-797-9085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI123431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4062594Medicaid