Provider Demographics
NPI:1104107903
Name:SULLIVAN, JOSEPH VINCENT (DDS)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:VINCENT
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 1:2109 CUMING ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68102-4325
Mailing Address - Country:US
Mailing Address - Phone:402-280-5990
Mailing Address - Fax:
Practice Address - Street 1:2109 CUMING ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102-4325
Practice Address - Country:US
Practice Address - Phone:406-250-7093
Practice Address - Fax:406-250-7093
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE602327591223G0001X
NE7685122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice