=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730413261
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGHAN KATHLEEN O'CONNELL D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2009
-----------------------------------------------------
Last Update Date | 07/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2748 WORTH RD SUITE 4
-----------------------------------------------------
City | FORT SAM HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78234-6031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-221-6326
-----------------------------------------------------
Fax | 210-221-7161
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2748 WORTH RD SUITE 4
-----------------------------------------------------
City | FORT SAM HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78234-6031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-221-6326
-----------------------------------------------------
Fax | 210-221-7161
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 6446-015
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 6446-015
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 6446-015
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 31686
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------