Healthcare Provider Details

I. General information

NPI: 1295815868
Provider Name (Legal Business Name): STEPHEN BARRY OBRIEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W NORTHWEST HWY SUITE 150
GRAPEVINE TX
76051-8113
US

IV. Provider business mailing address

1400 W NORTHWEST HWY SUITE 150
GRAPEVINE TX
76051-8113
US

V. Phone/Fax

Practice location:
  • Phone: 817-421-2855
  • Fax: 817-421-2704
Mailing address:
  • Phone: 817-421-2855
  • Fax: 817-421-2704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14346
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: