Provider Demographics
NPI:1962494047
Name:SULLIVAN, JOSEPH EARLE (DDS)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:EARLE
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 1:7128 LAWYERS RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-3906
Mailing Address - Country:US
Mailing Address - Phone:704-568-8010
Mailing Address - Fax:704-563-0496
Practice Address - Street 1:7128 LAWYERS RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-3906
Practice Address - Country:US
Practice Address - Phone:704-568-8010
Practice Address - Fax:704-563-0496
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4121122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U39464Medicare UPIN
NC8998207Medicare ID - Type Unspecified