Healthcare Provider Details

I. General information

NPI: 1649630534
Provider Name (Legal Business Name): JOSANNE MILDRED O'DELL D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2016
Last Update Date: 03/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 STEEPLEBROOK DR
CORDOVA TN
38016-5075
US

IV. Provider business mailing address

2060 STEEPLEBROOK DR
CORDOVA TN
38016-5075
US

V. Phone/Fax

Practice location:
  • Phone: 714-267-5205
  • Fax:
Mailing address:
  • Phone: 714-267-5205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number9970
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number39059
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: