Provider Demographics
NPI:1457412306
Name:SULLIVAN, JOHN J (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 W WHITE MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-6875
Mailing Address - Country:US
Mailing Address - Phone:928-367-4276
Mailing Address - Fax:928-367-1539
Practice Address - Street 1:325 W WHITE MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-6875
Practice Address - Country:US
Practice Address - Phone:928-367-4276
Practice Address - Fax:928-367-1539
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice