Provider Demographics
NPI:1528216959
Name:CONRAD, LORI MICHELLE ANDERSON (DMD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:MICHELLE ANDERSON
Last Name:CONRAD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MISS
Other - First Name:LORI
Other - Middle Name:MICHELLE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:6084 14TH ST W
Mailing Address - Street 2:SUITE B-5
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-4104
Mailing Address - Country:US
Mailing Address - Phone:941-727-8805
Mailing Address - Fax:
Practice Address - Street 1:6084 14TH ST W
Practice Address - Street 2:SUITE B-5
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-4104
Practice Address - Country:US
Practice Address - Phone:941-727-8805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY86851223G0001X
FLDN 20505122300000X
OH30-022877122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice