Provider Demographics
NPI:1700070646
Name:MARY M. O'CONNOR, DDS, INC
Entity type:Organization
Organization Name:MARY M. O'CONNOR, DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:MILDRED
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-291-5291
Mailing Address - Street 1:420 SPRUCE ST STE A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-5859
Mailing Address - Country:US
Mailing Address - Phone:619-291-5291
Mailing Address - Fax:619-291-9755
Practice Address - Street 1:420 SPRUCE ST STE A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5859
Practice Address - Country:US
Practice Address - Phone:619-291-5291
Practice Address - Fax:619-291-9755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA380721223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA514126OtherDENTI-CAL