Healthcare Provider Details

I. General information

NPI: 1598873580
Provider Name (Legal Business Name): SULLIVAN DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 08/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5436 COMMERCE ST
ST FRANCISVILLE LA
70775
US

IV. Provider business mailing address

PO BOX 2880
ST FRANCISVILLE LA
70775
US

V. Phone/Fax

Practice location:
  • Phone: 225-635-4422
  • Fax: 225-241-7155
Mailing address:
  • Phone: 225-635-4422
  • Fax: 225-635-2171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number5062
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number5558
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number4988
License Number StateLA

VIII. Authorized Official

Name: LILLIAN REYNOLDS
Title or Position: DIRECTOR
Credential:
Phone: 225-635-4422