Provider Demographics
NPI:1649457300
Name:SULLIVAN, MICHAEL ANTHONY
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6483 M 66 N
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-9272
Mailing Address - Country:US
Mailing Address - Phone:231-547-4191
Mailing Address - Fax:
Practice Address - Street 1:6483 M 66 N
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-9272
Practice Address - Country:US
Practice Address - Phone:231-547-4191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-24
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010199091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice