Healthcare Provider Details

I. General information

NPI: 1295926954
Provider Name (Legal Business Name): OCONNOR FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 SO 40TH AVE #15
YAKIMA WA
98908
US

IV. Provider business mailing address

1015 SO 40TH AVE #15
YAKIMA WA
98908
US

V. Phone/Fax

Practice location:
  • Phone: 509-966-0660
  • Fax:
Mailing address:
  • Phone: 509-966-0660
  • Fax: 509-965-0417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4241
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10492
License Number StateWA

VIII. Authorized Official

Name: NATHAN ANDREW OCONNOR
Title or Position: PARTNER
Credential:
Phone: 509-966-0660