Provider Demographics
NPI:1770502627
Name:O'CONNOR, SUSAN FRANCES (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:FRANCES
Last Name:O'CONNOR
Suffix:
Gender:F
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:PO BOX 1086
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-1086
Mailing Address - Country:US
Mailing Address - Phone:276-236-7408
Mailing Address - Fax:276-238-1016
Practice Address - Street 1:206 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2834
Practice Address - Country:US
Practice Address - Phone:276-236-7408
Practice Address - Fax:276-238-1016
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010076551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8200505Medicaid