Healthcare Provider Details

I. General information

NPI: 1871556472
Provider Name (Legal Business Name): PATRICIA ANNE SULLIVAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6274 SW CAPITOL HWY
PORTLAND OR
97239-2674
US

IV. Provider business mailing address

3560 SW BANCROFT CT
PORTLAND OR
97221-4029
US

V. Phone/Fax

Practice location:
  • Phone: 503-245-3656
  • Fax:
Mailing address:
  • Phone: 503-228-8321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD6652
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: