Provider Demographics
NPI:1346307683
Name:CONWAY, KATHERINE VERONICA (DDS)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:VERONICA
Last Name:CONWAY
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 1:955 HIGHWAY 55
Mailing Address - Street 2:SUITE 6
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-2365
Mailing Address - Country:US
Mailing Address - Phone:651-437-9764
Mailing Address - Fax:651-438-3138
Practice Address - Street 1:955 HIGHWAY 55
Practice Address - Street 2:SUITE 6
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-2365
Practice Address - Country:US
Practice Address - Phone:651-437-9764
Practice Address - Fax:651-438-3138
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN000724372OtherUNITED CONCORDIA
MN513823000Medicaid