Provider Demographics
NPI:1063564979
Name:SULLIVAN, JOHN K (DDS)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:K
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 1:498 HARLOW RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477
Mailing Address - Country:US
Mailing Address - Phone:541-225-4866
Mailing Address - Fax:888-502-2518
Practice Address - Street 1:498 HARLOW RD
Practice Address - Street 2:SUITE 1
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477
Practice Address - Country:US
Practice Address - Phone:541-225-4866
Practice Address - Fax:888-502-2518
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10371122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist