Provider Demographics
NPI:1770788721
Name:O'SHAUGHNESSY, KEVIN WILLIAM (DMD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:WILLIAM
Last Name:O'SHAUGHNESSY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 11TH AVE N APT 102
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-7265
Mailing Address - Country:US
Mailing Address - Phone:904-625-1578
Mailing Address - Fax:
Practice Address - Street 1:9640 CROSSHILL BLVD
Practice Address - Street 2:STE 101
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32222-5854
Practice Address - Country:US
Practice Address - Phone:904-404-4445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 168011223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics