Provider Demographics
NPI:1871026328
Name:SULLIVAN, MATTHIEU
Entity Type:Individual
Prefix:
First Name:MATTHIEU
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14003 E 89TH ST N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-2594
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4915 25TH AVE NE
Practice Address - Street 2:#205
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-5667
Practice Address - Country:US
Practice Address - Phone:206-524-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADR60745064122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist