Provider Demographics
NPI:1164516977
Name:CONNER, CHAUNCEY L (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHAUNCEY
Middle Name:L
Last Name:CONNER
Suffix:
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 1:1200 ERNEST W BARRETT PKWY NW STE 13
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-4543
Mailing Address - Country:US
Mailing Address - Phone:678-354-0079
Mailing Address - Fax:
Practice Address - Street 1:1200 ERNEST W BARRETT PKWY NW STE 13
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-4543
Practice Address - Country:US
Practice Address - Phone:678-354-0079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0128721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice