Provider Demographics
NPI:1033480694
Name:O'CONNOR, JAMES (DMD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 AGIN WAY
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:KY
Mailing Address - Zip Code:40045-1509
Mailing Address - Country:US
Mailing Address - Phone:502-268-3192
Mailing Address - Fax:502-268-5903
Practice Address - Street 1:25 AGIN WAY
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:KY
Practice Address - Zip Code:40045-1509
Practice Address - Country:US
Practice Address - Phone:502-268-3192
Practice Address - Fax:502-268-5903
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5403122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60054038Medicaid