Provider Demographics
NPI:1194733725
Name:SULLIVAN, JACKSON LEE (DDS, PA)
Entity type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:LEE
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 59TH ST W STE D
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-4639
Mailing Address - Country:US
Mailing Address - Phone:941-840-1906
Mailing Address - Fax:941-840-1906
Practice Address - Street 1:1906 59TH ST W STE D
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4639
Practice Address - Country:US
Practice Address - Phone:941-840-1906
Practice Address - Fax:941-840-1906
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN155291223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics