Provider Demographics
NPI:1134735277
Name:O'CONNOR, KYLE (DDS)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:O'CONNOR
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 1:132A PLEASANT HILL RD
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-9112
Mailing Address - Country:US
Mailing Address - Phone:360-480-3759
Mailing Address - Fax:
Practice Address - Street 1:2401 BORST AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-1411
Practice Address - Country:US
Practice Address - Phone:360-736-1151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61085949122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist