Individual
MS. MAENELL SULLIVAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DENTURIST DPD
Contact information
Practice address
296 SUSSEX AVE W, TENINO, WA 98589
(360) 264-5500
(360) 264-5500
Mailing address
PO BOX 1051, TENINO, WA 98589
(360) 264-5500
(360) 264-5500
Taxonomy
Speciality
Code
Description
License number
State
122400000X
Denturist
Primary
DN361
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5045273
DSHS
WA
Enumeration date
09/02/2006
Last updated
07/08/2007
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