Provider Demographics
NPI:1306987631
Name:SULLIVAN, STACY ANNE (DDS)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:ANNE
Last Name:SULLIVAN
Suffix:
Gender:F
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:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:YADKINVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27055-0457
Mailing Address - Country:US
Mailing Address - Phone:336-849-7777
Mailing Address - Fax:
Practice Address - Street 1:217 E WILLOW ST
Practice Address - Street 2:
Practice Address - City:YADKINVILLE
Practice Address - State:NC
Practice Address - Zip Code:27055-8193
Practice Address - Country:US
Practice Address - Phone:336-849-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC81091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902245Medicaid
NC3404399Medicaid