Provider Demographics
NPI:1760511299
Name:CONLEY, KIM THERESA (DDS)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:THERESA
Last Name:CONLEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 201849
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99520-1849
Mailing Address - Country:US
Mailing Address - Phone:907-792-6561
Mailing Address - Fax:
Practice Address - Street 1:1217 E 10TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-4003
Practice Address - Country:US
Practice Address - Phone:907-257-4683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1073122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD107FQMedicaid