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General NPI Number Information
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NPI Number | 1316239619
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Entity Type | Organization
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Legal Business Name | GRACIELA K SULLIVAN DDS INC
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Dates
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Enumeration Date | 05/05/2011
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Last Update Date | 05/05/2011
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Provider Practice Location Address
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Address Line | 5112 WARNER AVE STE 104
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City | HUNTINGTON BEACH
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State | CA
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Zip | 92649-6036
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Country | US
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Telephone | 714-377-2628
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Fax | 714-377-0090
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Provider Business Mailing Address
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Address Line | 5112 WARNER AVE STE 104
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City | HUNTINGTON BEACH
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State | CA
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Zip | 92649-6036
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Country | US
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Telephone | 714-377-2628
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MRS. GRACIELA K SULLIVAN
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Credential | D.D.S.
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Telephone | 714-377-2628
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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