Provider Demographics
NPI:1376701045
Name:O'NEILL, JAMES TERRENCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:TERRENCE
Last Name:O'NEILL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7845 CARNEGIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-5792
Mailing Address - Country:US
Mailing Address - Phone:260-423-2340
Mailing Address - Fax:260-969-4118
Practice Address - Street 1:7845 CARNEGIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:260-423-2340
Practice Address - Fax:260-969-4118
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010974A1223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2010252480Medicaid
OHH192110OtherMEDICAREPTAN