Provider Demographics
NPI:1255342028
Name:SULLIVANT, JOHN V (DDS,PA)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:V
Last Name:SULLIVANT
Suffix:
Gender:M
Credentials:DDS,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 N CARDINAL DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-3253
Mailing Address - Country:US
Mailing Address - Phone:870-425-4242
Mailing Address - Fax:870-425-4243
Practice Address - Street 1:727 N CARDINAL DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3253
Practice Address - Country:US
Practice Address - Phone:870-425-4242
Practice Address - Fax:870-425-4243
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR27881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice