Provider Demographics
NPI:1073668786
Name:CONDERATO, KATHLEEN ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ANN
Last Name:CONDERATO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30840 N 42ND PL
Mailing Address - Street 2:
Mailing Address - City:CAVE CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85331-5893
Mailing Address - Country:US
Mailing Address - Phone:419-564-5368
Mailing Address - Fax:
Practice Address - Street 1:7700 W ARROWHEAD TOWNE CTR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8616
Practice Address - Country:US
Practice Address - Phone:623-937-6453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD008598122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1073668786Medicaid
AZ1073668786Medicaid
1073668786Medicare NSC
AZ1073668786Medicare UPIN
AZ1073668786Medicare NSC