Provider Demographics
NPI:1740367598
Name:SULLIVAN, KENNETH JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JAMES
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 1:928 ARNOLD AVE
Mailing Address - Street 2:
Mailing Address - City:POINT PLEASANT BORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08742-2305
Mailing Address - Country:US
Mailing Address - Phone:732-899-0222
Mailing Address - Fax:732-892-5352
Practice Address - Street 1:928 ARNOLD AVE
Practice Address - Street 2:
Practice Address - City:POINT PLEASANT BORO
Practice Address - State:NJ
Practice Address - Zip Code:08742-2305
Practice Address - Country:US
Practice Address - Phone:732-899-0222
Practice Address - Fax:732-892-5352
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI014780001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice