Healthcare Provider Details

I. General information

NPI: 1972134567
Provider Name (Legal Business Name): SCOTT R SULLIVAN DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2020
Last Update Date: 02/18/2026
Certification Date: 02/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 E MONTCLAIR ST
SPRINGFIELD MO
65807-5076
US

IV. Provider business mailing address

4649 COLE AVE APT 116
DALLAS TX
75205-4043
US

V. Phone/Fax

Practice location:
  • Phone: 316-616-8157
  • Fax:
Mailing address:
  • Phone: 316-616-8157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2025018574
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: