Provider Demographics
NPI:1659434751
Name:O'DANIEL, DELORES MAE (DMD, PLC)
Entity Type:Individual
Prefix:DR
First Name:DELORES
Middle Name:MAE
Last Name:O'DANIEL
Suffix:
Gender:F
Credentials:DMD, PLC
Other - Prefix:MRS
Other - First Name:DELORES
Other - Middle Name:MAE
Other - Last Name:O'DANIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1064 BROOKS HILL RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BROOKS
Mailing Address - State:KY
Mailing Address - Zip Code:40109-5149
Mailing Address - Country:US
Mailing Address - Phone:502-955-1084
Mailing Address - Fax:502-955-1442
Practice Address - Street 1:1064 BROOKS HILL ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:BROOKS
Practice Address - State:KY
Practice Address - Zip Code:40109-1063
Practice Address - Country:US
Practice Address - Phone:502-955-1084
Practice Address - Fax:502-955-1442
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY56081223G0001X
IN12010483A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice