Provider Demographics
NPI:1437846342
Name:ALLISON, CONNER PATRICK
Entity Type:Individual
Prefix:
First Name:CONNER
Middle Name:PATRICK
Last Name:ALLISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 N CAUSEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-3116
Mailing Address - Country:US
Mailing Address - Phone:985-276-0206
Mailing Address - Fax:
Practice Address - Street 1:2030 N CAUSEWAY BLVD
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3116
Practice Address - Country:US
Practice Address - Phone:985-626-3338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-20
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA74111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty