Provider Demographics
NPI:1962535112
Name:O'CONNOR, DOUGLAS PATRICK (DMD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:PATRICK
Last Name:O'CONNOR
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:PO BOX 429
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:AL
Mailing Address - Zip Code:36401
Mailing Address - Country:US
Mailing Address - Phone:251-578-4444
Mailing Address - Fax:251-578-4444
Practice Address - Street 1:104 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:AL
Practice Address - Zip Code:36401
Practice Address - Country:US
Practice Address - Phone:251-578-4444
Practice Address - Fax:251-578-4444
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5089122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL24439Medicare UPIN