Provider Demographics
NPI:1750940615
Name:SULLIVAN, KEVIN THOMAS (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:THOMAS
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 1:22630 SNOWBIRD TRL
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:CO
Mailing Address - Zip Code:80467-8600
Mailing Address - Country:US
Mailing Address - Phone:508-574-8090
Mailing Address - Fax:
Practice Address - Street 1:675 SNAP DRAGON WAY UNIT 250
Practice Address - Street 2:
Practice Address - City:STEAMBOAT SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80487-2141
Practice Address - Country:US
Practice Address - Phone:970-457-4120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002040381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice