=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649606484
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIRK SULLIVAN D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2013
-----------------------------------------------------
Last Update Date | 09/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7823 FLORENCE AVE
-----------------------------------------------------
City | DOWNEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90240-3727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-927-6566
-----------------------------------------------------
Fax | 562-927-6599
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7823 FLORENCE AVE
-----------------------------------------------------
City | DOWNEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90240-3727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-927-6566
-----------------------------------------------------
Fax | 562-927-6599
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 38230
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------