Provider Demographics
NPI:1356438659
Name:MICHAEL T. O'DONNELL, D.M.D, P.A.
Entity type:Organization
Organization Name:MICHAEL T. O'DONNELL, D.M.D, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:O'DONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-622-5888
Mailing Address - Street 1:870 MACK BAYOU RD
Mailing Address - Street 2:STE. A
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-7150
Mailing Address - Country:US
Mailing Address - Phone:850-622-5888
Mailing Address - Fax:850-622-0072
Practice Address - Street 1:870 MACK BAYOU RD
Practice Address - Street 2:STE. A
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-7150
Practice Address - Country:US
Practice Address - Phone:850-622-5888
Practice Address - Fax:850-622-0072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 16800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty