Provider Demographics
NPI:1871168021
Name:SULLIVAN, DAVID J (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N9225 S SHORE DR
Mailing Address - Street 2:
Mailing Address - City:EAST TROY
Mailing Address - State:WI
Mailing Address - Zip Code:53120-2178
Mailing Address - Country:US
Mailing Address - Phone:262-366-4646
Mailing Address - Fax:
Practice Address - Street 1:525 E 68TH ST # F-2132
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:212-746-5115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI1002777-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program