Provider Demographics
NPI:1487950499
Name:R.L. SULLIVAN, D.D.S. INC.
Entity type:Organization
Organization Name:R.L. SULLIVAN, D.D.S. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL & MAXILLOFACIAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:413-967-5833
Mailing Address - Street 1:40 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:WARE
Mailing Address - State:MA
Mailing Address - Zip Code:01082-1234
Mailing Address - Country:US
Mailing Address - Phone:413-967-5833
Mailing Address - Fax:413-967-5933
Practice Address - Street 1:40 CHURCH ST
Practice Address - Street 2:
Practice Address - City:WARE
Practice Address - State:MA
Practice Address - Zip Code:01082-1234
Practice Address - Country:US
Practice Address - Phone:413-967-5833
Practice Address - Fax:413-967-5933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10928261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery