Provider Demographics
NPI:1154706539
Name:O'CONNELL, DEREK LEE (DMD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:LEE
Last Name:O'CONNELL
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 1:1811 ARMY BLVD
Mailing Address - Street 2:
Mailing Address - City:JBSA FT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-2686
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1811 ARMY BLVD
Practice Address - Street 2:
Practice Address - City:JBSA FT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-2686
Practice Address - Country:US
Practice Address - Phone:210-808-3736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31248122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist