Provider Demographics
NPI:1598899924
Name:O'GRADY, MICHAEL KEVIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KEVIN
Last Name:O'GRADY
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 1:2101 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8017
Mailing Address - Country:US
Mailing Address - Phone:631-666-6250
Mailing Address - Fax:631-666-6256
Practice Address - Street 1:2101 UNION BLVD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8017
Practice Address - Country:US
Practice Address - Phone:631-666-6250
Practice Address - Fax:631-666-6256
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0474651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice