MEDICARE: DR. JOHN F SULLIVAN D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry		IL

General Provider Information

NPI Number	:	1679657183
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN F SULLIVAN D.D.S.

Provider Business Mailing Address
First Line	:	1399 MAIN ST
Second Line	:
City	:	CRETE
State	:	IL
Zip	:	60417-2951
Country	:	US
Telephone Number	:	708-672-6440
Fax Number	:	708-672-6964

Provider Business Practice Location Address
First Line	:	1399 MAIN ST
Second Line	:
City	:	CRETE
State	:	IL
Zip	:	60417-2951
Country	:	US
Telephone Number	:	708-672-6440
Fax Number	:	708-672-6964

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	07/08/2007

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