Healthcare Provider Details

I. General information

NPI: 1487950499
Provider Name (Legal Business Name): R.L. SULLIVAN, D.D.S. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2011
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 CHURCH ST
WARE MA
01082-1234
US

IV. Provider business mailing address

40 CHURCH ST
WARE MA
01082-1234
US

V. Phone/Fax

Practice location:
  • Phone: 413-967-5833
  • Fax: 413-967-5933
Mailing address:
  • Phone: 413-967-5833
  • Fax: 413-967-5933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number10928
License Number StateMA

VIII. Authorized Official

Name: DR. ROBERT LAWRENCE SULLIVAN
Title or Position: ORAL & MAXILLOFACIAL SURGEON
Credential: D.D.S.
Phone: 413-967-5833