Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 18646 | CA |
NPI | 1003986928 |
---|---|
Provider Name | Larry D Sullivan |
First Address | Willits, CA 95490-4222 |
Second Address | Willits, CA 95490-4222 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/11/2006 |
Last Update Date | 08/07/2007 |