Provider Demographics
NPI:1366198467
Name:SULLIVAN, MATILDA DAUS (DDS)
Entity type:Individual
Prefix:
First Name:MATILDA
Middle Name:DAUS
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 BAINBRIDGE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1308
Mailing Address - Country:US
Mailing Address - Phone:434-610-7021
Mailing Address - Fax:
Practice Address - Street 1:1352 SOUTH ST # C5
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-1858
Practice Address - Country:US
Practice Address - Phone:267-909-9551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-28
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0444721223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry