Healthcare Provider Details

I. General information

NPI: 1629369947
Provider Name (Legal Business Name): JOHN CHARLES O'NEILL IV D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2011
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 EISENHOWER DR SUITE #4
SAVANNAH GA
31406-2632
US

IV. Provider business mailing address

310 EISENHOWER DR SUITE #4
SAVANNAH GA
31406-2632
US

V. Phone/Fax

Practice location:
  • Phone: 912-355-2688
  • Fax: 912-355-2657
Mailing address:
  • Phone: 912-355-2688
  • Fax: 912-355-2657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN014315
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: