1659434751 NPI number — DR. DELORES MAE O'DANIEL D.M.D., PLC

Table of content: DR. DELORES MAE O'DANIEL D.M.D., PLC (NPI 1659434751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659434751 NPI number — DR. DELORES MAE O'DANIEL D.M.D., PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'DANIEL
Provider First Name:
DELORES
Provider Middle Name:
MAE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.M.D., PLC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
O'DANIEL
Provider Other First Name:
DELORES
Provider Other Middle Name:
MAE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659434751
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1064 BROOKS HILL RD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
BROOKS
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40109-5149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-955-1084
Provider Business Mailing Address Fax Number:
502-955-1442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1064 BROOKS HILL ROAD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BROOKS
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40109-1063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-955-1084
Provider Business Practice Location Address Fax Number:
502-955-1442
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5608 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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