Provider Demographics
NPI:1033212576
Name:CONNER, JOHN RANDOLPH JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RANDOLPH
Last Name:CONNER
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 E 3900 S
Mailing Address - Street 2:#214
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-4414
Mailing Address - Country:US
Mailing Address - Phone:801-277-2637
Mailing Address - Fax:801-277-2638
Practice Address - Street 1:1345 E 3900 S
Practice Address - Street 2:#214
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-4414
Practice Address - Country:US
Practice Address - Phone:801-277-2637
Practice Address - Fax:801-277-2638
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1354219922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA869074OtherUNITED CONCORDIA