Basic Information
| Provider Information | |||||||||
| NPI: | 1023312089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'DONNELL | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1090 NORTHCHASE PKWY SE | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300676405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709165352 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4072 VICTORY BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237012820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574653834 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2011 | ||||||||
| LastUpdateDate: | 01/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 0401413071 | VA | Y | Dental Providers | Dentist | General Practice |
No ID Information.