Provider Demographics
NPI:1427621879
Name:SULLIVAN, SPIRIT (RDH)
Entity type:Individual
Prefix:
First Name:SPIRIT
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RDH
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 5395
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-5395
Mailing Address - Country:US
Mailing Address - Phone:505-982-4425
Mailing Address - Fax:505-982-8440
Practice Address - Street 1:6401 S RICHARDS AVE
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508-4887
Practice Address - Country:US
Practice Address - Phone:505-984-5048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
124Q00000X
NM124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist