Healthcare Provider Details

I. General information

NPI: 1962494047
Provider Name (Legal Business Name): JOSEPH EARLE SULLIVAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7128 LAWYERS RD
CHARLOTTE NC
28227-3906
US

IV. Provider business mailing address

7128 LAWYERS RD
CHARLOTTE NC
28227-3906
US

V. Phone/Fax

Practice location:
  • Phone: 704-568-8010
  • Fax: 704-563-0496
Mailing address:
  • Phone: 704-568-8010
  • Fax: 704-563-0496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4121
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: