Provider Demographics
NPI:1255307690
Name:O'NEAL, LATANYA A ((DDS))
Entity Type:Individual
Prefix:
First Name:LATANYA
Middle Name:A
Last Name:O'NEAL
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 1:201 W 8TH ST
Mailing Address - Street 2:SUITE 810
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3038
Mailing Address - Country:US
Mailing Address - Phone:719-562-4447
Mailing Address - Fax:719-583-1801
Practice Address - Street 1:9012 MATHIS AVE
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-5218
Practice Address - Country:US
Practice Address - Phone:571-921-1111
Practice Address - Fax:571-921-1112
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-26
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0122581223G0001X
VA04014119601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9180172OtherDORAL
GA822177721AMedicaid
VA9180172Medicaid