Healthcare Provider Details

I. General information

NPI: 1528329372
Provider Name (Legal Business Name): KEVAN O'NEILL DDS, MDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2012
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 DUDLEY ST MOC 180
PROVIDENCE RI
02905-3236
US

IV. Provider business mailing address

2 DUDLEY STREET MOC 180
PROVIDENCE RI
02905
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-2299
  • Fax: 401-444-2924
Mailing address:
  • Phone: 401-444-2299
  • Fax: 401-444-2924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.024958
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number056003
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDEN03205
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: