Provider Demographics
NPI:1871693705
Name:SULLIVAN, JENNIFER ANGELA (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANGELA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 ANDREWS HWY
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-3896
Mailing Address - Country:US
Mailing Address - Phone:432-218-7926
Mailing Address - Fax:
Practice Address - Street 1:3200 ANDREWS HWY
Practice Address - Street 2:SUITE 400
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-3896
Practice Address - Country:US
Practice Address - Phone:432-218-7926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX311701223X0400X
KY81601223X0400X
IN12011561A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9177836Medicaid
KY60003134Medicaid