Provider Demographics
NPI:1114428653
Name:O'BRIEN DENTAL PLLC
Entity type:Organization
Organization Name:O'BRIEN DENTAL PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:518-459-0711
Mailing Address - Street 1:107 EVERETT RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-6408
Mailing Address - Country:US
Mailing Address - Phone:518-459-0711
Mailing Address - Fax:518-459-0867
Practice Address - Street 1:2443 STATE ROUTE 9 STE 210
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-4518
Practice Address - Country:US
Practice Address - Phone:518-400-0735
Practice Address - Fax:518-677-1123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPENDINGMedicaid