Provider Demographics
NPI:1407840382
Name:CONELIAS, TRENT PAUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRENT
Middle Name:PAUL
Last Name:CONELIAS
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 1:6033 PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-3815
Mailing Address - Country:US
Mailing Address - Phone:757-424-2672
Mailing Address - Fax:757-366-0482
Practice Address - Street 1:6033 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-3815
Practice Address - Country:US
Practice Address - Phone:757-424-2672
Practice Address - Fax:757-366-0482
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA029325L1223S0112X
VA04014112851223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Not Answered1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU57941Medicare UPIN
PA800450Medicare ID - Type Unspecified