Provider Demographics
NPI:1669733424
Name:SULLIVAN, RYAN JOEL (DMD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:JOEL
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3176 ABBOTT RD
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1069
Mailing Address - Country:US
Mailing Address - Phone:716-827-1200
Mailing Address - Fax:
Practice Address - Street 1:4154 MCKINLEY PKWY
Practice Address - Street 2:
Practice Address - City:BLASDELL
Practice Address - State:NY
Practice Address - Zip Code:14219-2995
Practice Address - Country:US
Practice Address - Phone:716-649-2288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY056760122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program