Provider Demographics
NPI:1942795877
Name:SULLIVAN, CODY LEE (DDS)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:LEE
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 1:107 CHESTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23661-3210
Mailing Address - Country:US
Mailing Address - Phone:314-960-2064
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIR BLDG 1
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2111
Practice Address - Country:US
Practice Address - Phone:757-953-7591
Practice Address - Fax:757-953-7560
Is Sole Proprietor?:No
Enumeration Date:2018-06-23
Last Update Date:2018-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018021980122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist