Healthcare Provider Details

I. General information

NPI: 1104892306
Provider Name (Legal Business Name): THOMAS ALEXANDER SULLIVAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 38717 38TH STREET USA DENTAC
FT GORDON GA
30905-5660
US

IV. Provider business mailing address

NATTC NAVY DENTAL CLINIC 760 E. AVE. BUILD. 3911
PENSACOLA FL
32508
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-6927
  • Fax: 706-787-2082
Mailing address:
  • Phone: 850-452-8900
  • Fax: 850-452-8892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number11292
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: