Provider Demographics
NPI:1164800793
Name:CONBOY, MARY KATHLEEN (DMD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:CONBOY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 STATE ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-3926
Mailing Address - Country:US
Mailing Address - Phone:203-865-2245
Mailing Address - Fax:
Practice Address - Street 1:921 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3926
Practice Address - Country:US
Practice Address - Phone:203-865-2245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-14
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT11484122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program