Provider Demographics
NPI:1811048465
Name:SULLIVAN, JOSEPH CLABERON III (DDS)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:CLABERON
Last Name:SULLIVAN
Suffix:III
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 1:310 STAGECOACH TRL
Mailing Address - Street 2:SUITE 700
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-5134
Mailing Address - Country:US
Mailing Address - Phone:512-396-4288
Mailing Address - Fax:512-396-4379
Practice Address - Street 1:310 STAGECOACH TRL
Practice Address - Street 2:SUITE 700
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-5134
Practice Address - Country:US
Practice Address - Phone:512-396-4288
Practice Address - Fax:512-396-4379
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice