Provider Demographics
NPI:1265472948
Name:O'CONNOR, KATHLEEN M (DDS)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:M
Other - Last Name:O'CONNOR-MORAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 600
Mailing Address - Street 2:167 NORTH MAIN STREET
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045-0600
Mailing Address - Country:US
Mailing Address - Phone:928-283-2501
Mailing Address - Fax:928-283-2677
Practice Address - Street 1:167 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045-0600
Practice Address - Country:US
Practice Address - Phone:928-283-2501
Practice Address - Fax:928-283-2677
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-023010122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ422767Medicaid
8EC993Medicare ID - Type Unspecified
V09975Medicare UPIN