Individual
SCOTT R SULLIVAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS, MD
Contact information
Practice address
1103 E MONTCLAIR ST, SPRINGFIELD, MO 65807-5076
(316) 616-8157
Mailing address
4649 COLE AVE APT 116, DALLAS, TX 75205-4043
(316) 616-8157
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
2025018574
MO
390200000X
Student in an Organized Health Care Education/Training Program
Primary
—
—
Other
Enumeration date
02/01/2020
Last updated
02/18/2026
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