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General NPI Number Information
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NPI Number | 1780877571
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Entity Type | Organization
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Legal Business Name | SULLIVAN DENTISTRY,LLC
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Dates
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Enumeration Date | 08/24/2007
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Last Update Date | 08/24/2007
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Provider Practice Location Address
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Address Line | 920 GREENWALD CT STE 300
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City | MUKWONAGO
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State | WI
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Zip | 53149-1711
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Country | US
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Telephone | 262-642-2296
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Fax |
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Provider Business Mailing Address
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Address Line | N9225 S SHORE DR
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City | EAST TROY
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State | WI
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Zip | 53120-2178
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Country | US
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Telephone | 262-642-2296
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOHN S SULLIVAN
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Credential | DDS
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Telephone | 262-642-2296
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5098-015
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License Number State | WI
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