Provider Demographics
NPI:1992843965
Name:SULLINS, JAY SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:SCOTT
Last Name:SULLINS
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 1:8504 NW CACHE RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9604
Mailing Address - Country:US
Mailing Address - Phone:580-248-3636
Mailing Address - Fax:580-248-3533
Practice Address - Street 1:8504 NW CACHE RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9604
Practice Address - Country:US
Practice Address - Phone:580-248-3636
Practice Address - Fax:580-248-3533
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK381223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics