Provider Demographics
NPI:1295947448
Name:SULLIVAN ORTHODONTICS INC PS
Entity type:Organization
Organization Name:SULLIVAN ORTHODONTICS INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERENCE
Authorized Official - Middle Name:C
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:425-385-2641
Mailing Address - Street 1:15224 MAIN ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-7332
Mailing Address - Country:US
Mailing Address - Phone:425-385-2641
Mailing Address - Fax:425-385-2644
Practice Address - Street 1:15224 MAIN ST
Practice Address - Street 2:SUITE 302
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-7332
Practice Address - Country:US
Practice Address - Phone:425-385-2641
Practice Address - Fax:425-385-2644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000069111223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty