Provider Demographics
NPI:1992797468
Name:SULLIVAN, JOHN P (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:P
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 1:105 NEUCHATEL LN
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-4634
Mailing Address - Country:US
Mailing Address - Phone:585-586-7170
Mailing Address - Fax:
Practice Address - Street 1:60 TOBEY VILLAGE
Practice Address - Street 2:
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534-1858
Practice Address - Country:US
Practice Address - Phone:585-586-7170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055771-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY055771-1OtherNYS DENTAL LICENSE