Provider Demographics
NPI:1184038374
Name:O'BRIEN, KEVIN M
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 ROANOKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-5032
Mailing Address - Country:US
Mailing Address - Phone:540-389-0330
Mailing Address - Fax:
Practice Address - Street 1:511 ROANOKE BLVD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-5032
Practice Address - Country:US
Practice Address - Phone:540-389-0330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014144481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice