Provider Demographics
NPI:1871996199
Name:SULLIVAN FAMILY DENTISTRY, LLC
Entity type:Organization
Organization Name:SULLIVAN FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:W
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-268-4010
Mailing Address - Street 1:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IN
Mailing Address - Zip Code:47882-0468
Mailing Address - Country:US
Mailing Address - Phone:812-268-4010
Mailing Address - Fax:812-268-5607
Practice Address - Street 1:2186 N HOSPITAL BLVD., SUITE 1
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-0468
Practice Address - Country:US
Practice Address - Phone:812-268-4010
Practice Address - Fax:812-268-5607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007736A122300000X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100225990AMedicaid