Healthcare Provider Details

I. General information

NPI: 1518043967
Provider Name (Legal Business Name): WILLIAM CHARLES ODONNELL DMD PC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 SOUTH ST
PITTSFIELD MA
01201
US

IV. Provider business mailing address

12 SOUTHBROOK LANE
PITTSFIELD MA
01201
US

V. Phone/Fax

Practice location:
  • Phone: 413-443-0703
  • Fax: 413-443-0746
Mailing address:
  • Phone: 413-443-1793
  • Fax: 413-443-0746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number13078
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0331941
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: