Provider Demographics
NPI:1679628812
Name:O'CONNOR, KEVIN THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:THOMAS
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 CHRISTIAN LN
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-3510
Mailing Address - Country:US
Mailing Address - Phone:203-740-2123
Mailing Address - Fax:
Practice Address - Street 1:244 WESTCHESTER AVE
Practice Address - Street 2:SUITE 216
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10604-2907
Practice Address - Country:US
Practice Address - Phone:914-761-4090
Practice Address - Fax:914-761-5168
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0318581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01621874Medicaid