Provider Demographics
NPI:1598820532
Name:CONN, STACY ANN (DMDI BOARD CERTIFICA)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:ANN
Last Name:CONN
Suffix:
Gender:F
Credentials:DMDI BOARD CERTIFICA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:373 BOONE HEIGHTS DRIVE
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607
Mailing Address - Country:US
Mailing Address - Phone:828-264-0110
Mailing Address - Fax:
Practice Address - Street 1:373 BOONE HEIGHTS DRIVE
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607
Practice Address - Country:US
Practice Address - Phone:828-264-0110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC55831223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8991761Medicaid
BC1027742OtherDEA
U36904Medicare UPIN