Provider Demographics
NPI:1780877571
Name:SULLIVAN DENTISTRY,LLC
Entity type:Organization
Organization Name:SULLIVAN DENTISTRY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-642-2296
Mailing Address - Street 1:N9225 S SHORE DR
Mailing Address - Street 2:
Mailing Address - City:EAST TROY
Mailing Address - State:WI
Mailing Address - Zip Code:53120-2178
Mailing Address - Country:US
Mailing Address - Phone:262-642-2296
Mailing Address - Fax:
Practice Address - Street 1:920 GREENWALD CT
Practice Address - Street 2:STE 300
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-1711
Practice Address - Country:US
Practice Address - Phone:262-642-2296
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5098-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty