Provider Demographics
NPI:1164716338
Name:O'BRIEN, COLLEEN M (DDS)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 337
Mailing Address - Street 2:
Mailing Address - City:SCARBRO
Mailing Address - State:WV
Mailing Address - Zip Code:25917-0337
Mailing Address - Country:US
Mailing Address - Phone:304-574-2076
Mailing Address - Fax:304-574-1068
Practice Address - Street 1:75 SPYROCK LOOP ROAD
Practice Address - Street 2:
Practice Address - City:LOOKOUT
Practice Address - State:WV
Practice Address - Zip Code:25868
Practice Address - Country:US
Practice Address - Phone:304-574-2076
Practice Address - Fax:304-574-1068
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-023656122300000X
WV41231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810028195Medicaid
WVWV5033AMedicare UPIN