MEDICARE: BRETT MICHAEL SULLIVAN D.M.D., M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	D9737	OR
2	122300000X	Dentist	2007019263	MO

General Provider Information

NPI Number	:	1629268966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRETT MICHAEL SULLIVAN D.M.D., M.D.

Provider Business Mailing Address
First Line	:	11211 SE SUNNYSIDE RD
Second Line	:
City	:	CLACKAMAS
State	:	OR
Zip	:	97015-7787
Country	:	US
Telephone Number	:	503-652-8080
Fax Number	:	503-289-9621

Provider Business Practice Location Address
First Line	:	11211 SE SUNNYSIDE RD
Second Line	:
City	:	CLACKAMAS
State	:	OR
Zip	:	97015-7787
Country	:	US
Telephone Number	:	503-652-8080
Fax Number	:	503-526-8992

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2007
Last Update Date	:	12/06/2024

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