Provider Demographics
NPI:1114231123
Name:CONLISK, ALBERT TERRENCE III (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:TERRENCE
Last Name:CONLISK
Suffix:III
Gender:M
Credentials:DDS, MD
Other - Prefix:
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Mailing Address - Street 1:1976 GRANVILLE RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-9799
Mailing Address - Country:US
Mailing Address - Phone:740-231-2121
Mailing Address - Fax:740-231-5255
Practice Address - Street 1:1976 GRANVILLE RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-9799
Practice Address - Country:US
Practice Address - Phone:740-231-2121
Practice Address - Fax:740-231-5255
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010202331223S0112X
OH30.247761223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery