Basic Information
| Provider Information | |||||||||
| NPI: | 1619949377 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | BARRY | ||||||||
| MiddleName: | |||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4009 N FLOWING WELLS RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857052404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204080836 | ||||||||
| FaxNumber: | 5202932964 | ||||||||
| Practice Location | |||||||||
| Address1: | 4009 N FLOWING WELLS RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857052404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204080836 | ||||||||
| FaxNumber: | 5202932964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 5607 | AZ | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 695926 | 05 | AZ | MEDICAID |