Provider Demographics
NPI:1104892306
Name:SULLIVAN, THOMAS ALEXANDER (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ALEXANDER
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:NATTC NAVY DENTAL CLINIC
Mailing Address - Street 2:760 E. AVE. BUILD. 3911
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32508
Mailing Address - Country:US
Mailing Address - Phone:850-452-8900
Mailing Address - Fax:850-452-8892
Practice Address - Street 1:BLDG 38717 38TH STREET
Practice Address - Street 2:USA DENTAC
Practice Address - City:FT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5660
Practice Address - Country:US
Practice Address - Phone:706-787-6927
Practice Address - Fax:706-787-2082
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11292122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist