Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 220385 | MS |
NPI | 1003098609 |
---|---|
Provider Name | Dr. Randy Lee Sullivan |
First Address | Southaven, MS 38671 |
Second Address | Southaven, MS 38671 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/12/2007 |
Last Update Date | 05/12/2007 |