Provider Demographics
NPI:1518526805
Name:CONIAM, MICHAEL PHILLIP (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PHILLIP
Last Name:CONIAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20496 N 93RD LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-5259
Mailing Address - Country:US
Mailing Address - Phone:602-510-9838
Mailing Address - Fax:
Practice Address - Street 1:7611 W THOMAS RD STE E002
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-5454
Practice Address - Country:US
Practice Address - Phone:623-869-1091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD010327122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty