Provider Demographics
NPI:1952632507
Name:SULLIVAN, DAVID JOSEPH (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOSEPH
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2326
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97709-2326
Mailing Address - Country:US
Mailing Address - Phone:541-316-2024
Mailing Address - Fax:541-504-2124
Practice Address - Street 1:413 NW LARCH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1361
Practice Address - Country:US
Practice Address - Phone:541-316-2024
Practice Address - Fax:541-504-2124
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD93841223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics