Healthcare Provider Details

I. General information

NPI: 1942795877
Provider Name (Legal Business Name): CODY LEE SULLIVAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2018
Last Update Date: 02/03/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MERCY CIRCLE
CAMP PENDLETON CA
92055-5191
US

IV. Provider business mailing address

200 MERCY CIRCLE
CAMP PENDLETON CA
92005
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-3417
  • Fax:
Mailing address:
  • Phone: 760-725-3879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401418537
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2018021980
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: