Provider Demographics
NPI:1639782709
Name:CONN, COURTNEY BULLARD (DMD)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:BULLARD
Last Name:CONN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 NANTUCKET RD # B
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-2168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 HWY 55
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:NC
Practice Address - Zip Code:28365
Practice Address - Country:US
Practice Address - Phone:919-658-9555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC118551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice