Andrea Lee Sullivan, DMD

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

2018003588 Issued in MO

Practice address

3024 South Il-159
Glen Carbon, IL 62034

Phone

(855) 579-2158

NPI assigned

Feb 8, 2018

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1518048000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1521244800000",
    "number": "1871092502",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "902 MONTEREY DR",
            "city": "O FALLON",
            "state": "IL",
            "postal_code": "622692833",
            "telephone_number": "618-975-7454"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3024 SOUTH IL-159",
            "city": "GLEN CARBON",
            "state": "IL",
            "postal_code": "62034",
            "telephone_number": "855-579-2158"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1200 Big Bill Rd",
            "address_purpose": "LOCATION",
            "city": "Arnold",
            "state": "MO",
            "postal_code": "630102117",
            "country_code": "US",
            "telephone_number": "636-925-2129",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1809 Homer M Adams Pkwy Ste A",
            "address_purpose": "LOCATION",
            "city": "Alton",
            "state": "IL",
            "postal_code": "620025606",
            "country_code": "US",
            "telephone_number": "844-219-0605",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "SULLIVAN",
        "first_name": "ANDREA",
        "middle_name": "LEE",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2018-02-08",
        "last_updated": "2018-03-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MO",
            "license": "2018003588",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MISSOURI DENTAL BOARD",
            "identifier": "2018003588",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• General Practice Dentistry in Glen Carbon, IL
• Providers in Glen Carbon, IL by specialty
• General Practice Dentistry in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 17, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.