Provider Demographics
NPI:1134414865
Name:SULLIVAN, KRISTEN NICOLE (DMD)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NICOLE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W ERIE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-6914
Mailing Address - Country:US
Mailing Address - Phone:920-838-1649
Mailing Address - Fax:
Practice Address - Street 1:5675 N FRONT ST
Practice Address - Street 2:SUITE 50
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120
Practice Address - Country:US
Practice Address - Phone:920-838-1649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038712122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist