=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104011808
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SYCAMORE FAMILY DENTISTRY, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2007
-----------------------------------------------------
Last Update Date | 09/06/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 645 PLAZA DR
-----------------------------------------------------
City | SYCAMORE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60178-2719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-895-2298
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 645 PLAZA DR
-----------------------------------------------------
City | SYCAMORE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60178-2719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-895-2298
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. JOSEPH T SULLIVAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 815-895-2298
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------