Healthcare Provider Details

I. General information

NPI: 1558385815
Provider Name (Legal Business Name): DANIEL JAMES SULLIVAN III D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N MAIN ST
MOSCOW PA
18444-9020
US

IV. Provider business mailing address

109 N MAIN ST
MOSCOW PA
18444-9020
US

V. Phone/Fax

Practice location:
  • Phone: 570-842-4255
  • Fax: 570-842-0477
Mailing address:
  • Phone: 570-842-4255
  • Fax: 570-842-0477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS019800L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: