Provider Demographics
NPI:1487668612
Name:CONLON, ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:CONLON
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 1:312 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-1904
Mailing Address - Country:US
Mailing Address - Phone:262-248-8766
Mailing Address - Fax:262-248-6790
Practice Address - Street 1:312 CENTER ST
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-1904
Practice Address - Country:US
Practice Address - Phone:262-248-8766
Practice Address - Fax:262-248-6790
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24901223S0112X
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT37819Medicare UPIN
IL683930Medicare ID - Type Unspecified
WI76484Medicare ID - Type Unspecified