Basic Information
| Provider Information | |||||||||
| NPI: | 1376701045 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'NEILL | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | TERRENCE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7845 CARNEGIE BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468045792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604232340 | ||||||||
| FaxNumber: | 2609694118 | ||||||||
| Practice Location | |||||||||
| Address1: | 7845 CARNEGIE BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604232340 | ||||||||
| FaxNumber: | 2609694118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2008 | ||||||||
| LastUpdateDate: | 07/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 12010974A | IN | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 204E00000X | 12010974A | IN | N | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2010252480 | 05 | IN | MEDICAID | H192110 | 01 | OH | MEDICAREPTAN | OTHER |