=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992797468
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN P. SULLIVAN D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2005
-----------------------------------------------------
Last Update Date | 01/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 TOBEY VILLAGE
-----------------------------------------------------
City | PITTSFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14534-1858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-586-7170
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 NEUCHATEL LN
-----------------------------------------------------
City | FAIRPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14450-4634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-586-7170
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 055771-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------