Provider Demographics
NPI:1962558106
Name:SULLIVAN, KYLE (DMD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
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 1:121 W POPLAR ST
Mailing Address - Street 2:STE A
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2871
Mailing Address - Country:US
Mailing Address - Phone:509-525-3522
Mailing Address - Fax:
Practice Address - Street 1:121 W POPLAR ST
Practice Address - Street 2:STE A
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2871
Practice Address - Country:US
Practice Address - Phone:509-525-3522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5366921-99221223G0001X
WADE600832621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA45-0951861OtherTIN