Provider Demographics
NPI:1457541336
Name:DAVID K. SULLIVAN, DMD, PA
Entity Type:Organization
Organization Name:DAVID K. SULLIVAN, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-724-5544
Mailing Address - Street 1:9550 REGENCY SQUARE BLVD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-8116
Mailing Address - Country:US
Mailing Address - Phone:904-724-5544
Mailing Address - Fax:904-725-2522
Practice Address - Street 1:9550 REGENCY SQUARE BLVD
Practice Address - Street 2:SUITE 600
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-8116
Practice Address - Country:US
Practice Address - Phone:904-724-5544
Practice Address - Fax:904-725-2522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL89931223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty