Provider Demographics
NPI:1871092502
Name:SULLIVAN, ANDREA LEE (DMD)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:LEE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 MONTEREY DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2833
Mailing Address - Country:US
Mailing Address - Phone:618-975-7454
Mailing Address - Fax:
Practice Address - Street 1:3024 SOUTH IL-159
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034
Practice Address - Country:US
Practice Address - Phone:855-579-2158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180035881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2018003588OtherMISSOURI DENTAL BOARD