Provider Demographics
NPI:1649321522
Name:SULLIVAN, COLLINS JOSEPH (DDS)
Entity type:Individual
Prefix:MR
First Name:COLLINS
Middle Name:JOSEPH
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 1:967 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030-6756
Mailing Address - Country:US
Mailing Address - Phone:805-487-0435
Mailing Address - Fax:805-487-2119
Practice Address - Street 1:967 W 7TH ST
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-6756
Practice Address - Country:US
Practice Address - Phone:805-487-0435
Practice Address - Fax:805-487-2119
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0333841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA033384OtherSTATE LICENSE