Provider Demographics
NPI:1356569107
Name:O'LEARY, BRIAN COSTELLO (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:COSTELLO
Last Name:O'LEARY
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1544 OLD TAMAH RD
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-9000
Mailing Address - Country:US
Mailing Address - Phone:803-732-7223
Mailing Address - Fax:803-732-5985
Practice Address - Street 1:1544 OLD TAMAH RD
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-9000
Practice Address - Country:US
Practice Address - Phone:803-732-7223
Practice Address - Fax:803-732-5985
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3493 (ORTHO-542)1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics