Basic Information
| Provider Information | |||||||||
| NPI: | 1588614630 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | WALTER | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6810 POST RD | ||||||||
| Address2: | |||||||||
| City: | NORTH KINGSTOWN | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018841525 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6810 POST RD | ||||||||
| Address2: | |||||||||
| City: | NORTH KINGSTOWN | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018841525 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| 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 | 122300000X | 1685 | RI | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 83825 | 01 | RI | BLUE CROSS BLUE SHIELD | OTHER | 1685 | 01 | RI | DELTA DENTAL | OTHER |