Healthcare Provider Details

I. General information

NPI: 1063683472
Provider Name (Legal Business Name): STEPHANIE SULLIVAN TULLOS DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

276 MAGNOLIA DR
RALEIGH MS
39153-6016
US

IV. Provider business mailing address

276 MAGNOLIA DR
RALEIGH MS
39153-6016
US

V. Phone/Fax

Practice location:
  • Phone: 601-782-9909
  • Fax: 601-782-9133
Mailing address:
  • Phone: 601-782-9909
  • Fax: 601-782-9133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3265-03
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: