Provider Demographics
NPI:1700128477
Name:O'LEARY, KOLLEEN FAYE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:KOLLEEN
Middle Name:FAYE
Last Name:O'LEARY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40655 W 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-3504
Mailing Address - Country:US
Mailing Address - Phone:248-478-0765
Mailing Address - Fax:
Practice Address - Street 1:1495 FORT ST
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-3036
Practice Address - Country:US
Practice Address - Phone:734-330-1560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902009245124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist