Healthcare Provider Details

I. General information

NPI: 1912573023
Provider Name (Legal Business Name): ANDREW J SULLIVAN DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2021
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 NORTHPARK DR STE C
COLUMBUS IN
47203-4482
US

IV. Provider business mailing address

2320 NORTHPARK DR STE C
COLUMBUS IN
47203-4482
US

V. Phone/Fax

Practice location:
  • Phone: 812-552-2320
  • Fax:
Mailing address:
  • Phone: 317-604-6787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12013628A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: