Provider Demographics
NPI:1639386915
Name:O'LEARY, KEVIN S (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:S
Last Name:O'LEARY
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 1:2004 W COURT ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-3470
Mailing Address - Country:US
Mailing Address - Phone:608-758-2004
Mailing Address - Fax:608-758-2443
Practice Address - Street 1:2004 W COURT ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-3470
Practice Address - Country:US
Practice Address - Phone:608-758-2004
Practice Address - Fax:608-758-2443
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4303122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist