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General NPI Number Information
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NPI Number | 1477616662
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Entity Type | Individual
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Provider Name | PREDDIS LEROY SULLIVAN DDS
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Gender | Male
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Dates
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Enumeration Date | 12/18/2006
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Last Update Date | 10/06/2022
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Provider Practice Location Address
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Address Line | 1619 N WATERFRONT PKWY
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City | WICHITA
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State | KS
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Zip | 67206-6602
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Country | US
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Telephone | 316-462-3354
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Fax |
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Provider Business Mailing Address
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Address Line | 3620 N CREST CT
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City | WICHITA
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State | KS
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Zip | 67226-1019
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Country | US
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Telephone | 916-517-9905
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 54500
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License Number State | CA
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