Provider Demographics
NPI:1588833917
Name:OCONNOR, KELLY L (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:L
Last Name:OCONNOR
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 1:801 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914
Mailing Address - Country:US
Mailing Address - Phone:815-932-3516
Mailing Address - Fax:815-932-2992
Practice Address - Street 1:801 MAIN ST
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914
Practice Address - Country:US
Practice Address - Phone:815-932-3516
Practice Address - Fax:815-932-2992
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019020584122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist