Provider Demographics
NPI:1295926954
Name:OCONNOR FAMILY DENTISTRY
Entity type:Organization
Organization Name:OCONNOR FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:OCONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-966-0660
Mailing Address - Street 1:1015 SO 40TH AVE
Mailing Address - Street 2:#15
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908
Mailing Address - Country:US
Mailing Address - Phone:509-966-0660
Mailing Address - Fax:509-965-0417
Practice Address - Street 1:1015 SO 40TH AVE
Practice Address - Street 2:#15
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908
Practice Address - Country:US
Practice Address - Phone:509-966-0660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA104921223G0001X
WA4241122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5051040Medicaid