Provider Demographics
NPI:1841282027
Name:O'NEILL, BRIAN M (DDS)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:M
Last Name:O'NEILL
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 1:4646 NANTUCKET DR
Mailing Address - Street 2:STE A
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-3194
Mailing Address - Country:US
Mailing Address - Phone:419-843-2121
Mailing Address - Fax:419-517-2104
Practice Address - Street 1:970 W WOOSTER ST
Practice Address - Street 2:STE 126
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2643
Practice Address - Country:US
Practice Address - Phone:419-353-2100
Practice Address - Fax:419-353-6606
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-02-10691223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000127870OtherANTHEM BC
OH190010049OtherRR MEDICARE
OH2171368Medicaid
OH190010050OtherRR MEDICARE
OH4014055Medicare PIN
U79456Medicare UPIN
OH190010050OtherRR MEDICARE
OH4014053Medicare PIN