Basic Information
| Provider Information | |||||||||
| NPI: | 1164716338 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'BRIEN | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 337 | ||||||||
| Address2: | |||||||||
| City: | SCARBRO | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259170337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045742076 | ||||||||
| FaxNumber: | 3045741068 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 SPYROCK LOOP ROAD | ||||||||
| Address2: | |||||||||
| City: | LOOKOUT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045742076 | ||||||||
| FaxNumber: | 3045741068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2011 | ||||||||
| LastUpdateDate: | 10/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 30-023656 | OH | N | Dental Providers | Dentist | 1223G0001X | 4123 | WV | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 3810028195 | 05 | WV | MEDICAID |