Healthcare Provider Details

I. General information

NPI: 1316239619
Provider Name (Legal Business Name): GRACIELA K SULLIVAN DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2011
Last Update Date: 05/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5112 WARNER AVE STE 104
HUNTINGTON BEACH CA
92649-6036
US

IV. Provider business mailing address

5112 WARNER AVE STE 104
HUNTINGTON BEACH CA
92649-6036
US

V. Phone/Fax

Practice location:
  • Phone: 714-377-2628
  • Fax: 714-377-0090
Mailing address:
  • Phone: 714-377-2628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. GRACIELA K SULLIVAN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: D.D.S.
Phone: 714-377-2628