Provider Demographics
NPI:1164537742
Name:O'DONNELL, MICHAEL (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:O'DONNELL
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 1:37 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:ISELIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08830-2139
Mailing Address - Country:US
Mailing Address - Phone:732-283-1735
Mailing Address - Fax:
Practice Address - Street 1:37 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:ISELIN
Practice Address - State:NJ
Practice Address - Zip Code:08830-2139
Practice Address - Country:US
Practice Address - Phone:732-283-1735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI013024001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice