Provider Demographics
NPI:1336366244
Name:JACKSON L. SULLIVAN D.D.S., P.C.
Entity Type:Organization
Organization Name:JACKSON L. SULLIVAN D.D.S., P.C.
Other - Org Name:EDMOND ENDODONTICS
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:L
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-844-8444
Mailing Address - Street 1:609 S KELLY AVE STE E1
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-7501
Mailing Address - Country:US
Mailing Address - Phone:405-844-8444
Mailing Address - Fax:405-844-8440
Practice Address - Street 1:609 S KELLY AVE STE E1
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-7501
Practice Address - Country:US
Practice Address - Phone:405-844-8444
Practice Address - Fax:405-844-8440
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSON L. SULLIVAN D.D.S., P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-20
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK52441223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty