Provider Demographics
NPI:1780827543
Name:DAVID J.CONNER D.D.S.
Entity Type:Organization
Organization Name:DAVID J.CONNER D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:CONNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:601-947-4828
Mailing Address - Street 1:PO BOX 707
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-0707
Mailing Address - Country:US
Mailing Address - Phone:601-947-4828
Mailing Address - Fax:601-947-4829
Practice Address - Street 1:17215 HWY 26
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452
Practice Address - Country:US
Practice Address - Phone:601-947-4828
Practice Address - Fax:601-947-4829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1664-75122300000X
LAD2697122300000X
LA5712122300000X
MS3392-06122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03306702Medicaid
MS07288757Medicaid