Provider Demographics
NPI:1568569416
Name:KATHERINE V. CONWAY D.D.S. P. A
Entity Type:Organization
Organization Name:KATHERINE V. CONWAY D.D.S. P. A
Other - Org Name:HASTINGS FAMILY DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:VERONICA
Authorized Official - Last Name:CONWAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-437-9764
Mailing Address - Street 1:955 HIGHWAY 55
Mailing Address - Street 2:SUITE 6
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-2365
Mailing Address - Country:US
Mailing Address - Phone:651-437-9764
Mailing Address - Fax:651-438-3138
Practice Address - Street 1:955 HIGHWAY 55
Practice Address - Street 2:SUITE 6
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-2365
Practice Address - Country:US
Practice Address - Phone:651-437-9764
Practice Address - Fax:651-438-3138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101481223G0001X
MN101011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000724372OtherUNITED CONCORDIA
MN513823000Medicaid