Provider Demographics
NPI:1629120209
Name:O'BRIEN, JOHN ANDREW (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANDREW
Last Name:O'BRIEN
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 1:5301 E STATE ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2901
Mailing Address - Country:US
Mailing Address - Phone:815-399-2542
Mailing Address - Fax:
Practice Address - Street 1:5301 E STATE ST
Practice Address - Street 2:SUITE 306
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2901
Practice Address - Country:US
Practice Address - Phone:815-399-2542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice