Provider Demographics
NPI:1659954279
Name:SCHWARTZ, CONNOR FLYNN
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:FLYNN
Last Name:SCHWARTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 N DUPONT SQ
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4663
Mailing Address - Country:US
Mailing Address - Phone:502-893-5677
Mailing Address - Fax:
Practice Address - Street 1:1005 N DUPONT SQ
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4663
Practice Address - Country:US
Practice Address - Phone:502-893-5677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-02
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY106001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program