Individual
DR. ANDREA LEE SULLIVAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DMD
Contact information
Practice address
3024 SOUTH IL-159, GLEN CARBON, IL 62034
(855) 579-2158
Mailing address
902 MONTEREY DR, O FALLON, IL 62269-2833
(618) 975-7454
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
2018003588
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2018003588
MISSOURI DENTAL BOARD
MO
Enumeration date
02/08/2018
Last updated
03/17/2018
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