Provider Demographics
NPI:1194823112
Name:OBRIEN, MEGHAN KEELY (DDS)
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:KEELY
Last Name:OBRIEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MEGHAN
Other - Middle Name:KEELY
Other - Last Name:OBRIEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:707 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409
Mailing Address - Country:US
Mailing Address - Phone:715-627-4391
Mailing Address - Fax:715-627-4392
Practice Address - Street 1:707 6TH AVE
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409
Practice Address - Country:US
Practice Address - Phone:715-627-4391
Practice Address - Fax:715-627-4392
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55070151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice