Provider Demographics
NPI:1144906603
Name:ULLRICH, SUKI ROSE (DMD)
Entity type:Individual
Prefix:
First Name:SUKI
Middle Name:ROSE
Last Name:ULLRICH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2007
Mailing Address - Country:US
Mailing Address - Phone:401-741-1462
Mailing Address - Fax:
Practice Address - Street 1:190 PARK AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1000
Practice Address - Country:US
Practice Address - Phone:207-874-1028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN5178122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist