Provider Demographics
NPI:1336547280
Name:SULLIVAN FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:SULLIVAN FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALLYCE
Authorized Official - Middle Name:COLETTE
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-692-8289
Mailing Address - Street 1:1209 SOMERSET AVE
Mailing Address - Street 2:#3
Mailing Address - City:DIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02715-1224
Mailing Address - Country:US
Mailing Address - Phone:508-692-8289
Mailing Address - Fax:
Practice Address - Street 1:1209 SOMERSET AVE
Practice Address - Street 2:#3
Practice Address - City:DIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02715-1224
Practice Address - Country:US
Practice Address - Phone:508-692-8289
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty