Provider Demographics
NPI:1316931868
Name:SULLIVAN, CORNELIUS JOSEPH (DMD)
Entity type:Individual
Prefix:DR
First Name:CORNELIUS
Middle Name:JOSEPH
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 WEST ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3400
Mailing Address - Country:US
Mailing Address - Phone:410-268-7790
Mailing Address - Fax:410-268-7874
Practice Address - Street 1:275 WEST ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3400
Practice Address - Country:US
Practice Address - Phone:410-268-7790
Practice Address - Fax:410-268-7874
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-09
Last Update Date:2007-07-08
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-14
Provider Licenses
StateLicense IDTaxonomies
MD103571223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
U05316Medicare UPIN
MD710BMedicare ID - Type Unspecified