Healthcare Provider Details

I. General information

NPI: 1073966917
Provider Name (Legal Business Name): RYAN PATRICK O'SULLIVAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1998 N COLLEGE AVE
FAYETTEVILLE AR
72703-2609
US

IV. Provider business mailing address

1998 N COLLEGE AVE
FAYETTEVILLE AR
72703-2609
US

V. Phone/Fax

Practice location:
  • Phone: 479-222-1118
  • Fax:
Mailing address:
  • Phone: 479-222-1118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4213
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: