Provider Demographics
NPI:1538151725
Name:O'BRIEN, JODY J (DDS)
Entity type:Individual
Prefix:DR
First Name:JODY
Middle Name:J
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:250 FULLER ST S
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-1681
Mailing Address - Country:US
Mailing Address - Phone:952-445-6657
Mailing Address - Fax:952-445-0674
Practice Address - Street 1:250 FULLER ST S
Practice Address - Street 2:SUITE 250
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-1681
Practice Address - Country:US
Practice Address - Phone:952-445-6657
Practice Address - Fax:952-445-0674
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN11027122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3945243-00OtherMN HEALTH CARE PROGRAM