Healthcare Provider Details

I. General information

NPI: 1609836741
Provider Name (Legal Business Name): JOHN JOSEPH O'CONNELL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10448 SAINT ANN LN
SAINT ANN MO
63074-3525
US

IV. Provider business mailing address

10448 SAINT ANN LN
SAINT ANN MO
63074-3525
US

V. Phone/Fax

Practice location:
  • Phone: 314-426-0767
  • Fax: 314-426-7080
Mailing address:
  • Phone: 314-426-0767
  • Fax: 314-426-7080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12311
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: