Maenell Sullivan, DENTURIST DPD
Individual provider Active NPI Denturist · Tenino, WA
NPI 1679675367 · NPPES record last updated Jul 8, 2007
Key facts
- NPI
- 1679675367
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Denturist 122400000X
- License
- DN361 (WA)
- Practice address
- 296 Sussex Ave W
Tenino, WA 98589 - Phone
- (360) 264-5500
- Fax
- (360) 264-5500
- NPI assigned
- Sep 2, 2006
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DN361 | WA | MD | Denturist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Tenino Denture Center, LLC | Denturist | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Denturist | 122400000X | DN361 | WA | Yes |
Addresses
Primary practice location
296 Sussex Ave W
Tenino, WA 98589
Mailing address
PO Box 1051
Tenino, WA 98589
Phone (360) 264-5500
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 5045273 | Other | WA | DSHS |
Other providers in Tenino, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 8, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.