Provider Demographics
NPI:1629354428
Name:CONNER DENTISTRY LLC
Entity Type:Organization
Organization Name:CONNER DENTISTRY LLC
Other - Org Name:FAMILY DENTISTRY OF WABASH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:CONNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-563-4805
Mailing Address - Street 1:1146 N CASS ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-1081
Mailing Address - Country:US
Mailing Address - Phone:260-563-4805
Mailing Address - Fax:260-563-2958
Practice Address - Street 1:1146 N CASS ST
Practice Address - Street 2:SUITE C
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-1081
Practice Address - Country:US
Practice Address - Phone:260-563-4805
Practice Address - Fax:260-563-2958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011312122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty