Provider Demographics
NPI:1487175634
Name:O'BRIEN, JOHNATHON
Entity type:Individual
Prefix:
First Name:JOHNATHON
Middle Name:
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7059 DODGE ST STE 102
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68132-2703
Mailing Address - Country:US
Mailing Address - Phone:402-686-6186
Mailing Address - Fax:
Practice Address - Street 1:3225 OAK VIEW DR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-5627
Practice Address - Country:US
Practice Address - Phone:402-972-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA093951223G0001X
WI101359-8751223G0001X
NE73731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice