Provider Demographics
NPI:1821429747
Name:CONWAY, STEPHEN
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:CONWAY
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:STEVE
Other - Middle Name:
Other - Last Name:CONWAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:5 WEDGEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3762
Mailing Address - Country:US
Mailing Address - Phone:618-656-1713
Mailing Address - Fax:
Practice Address - Street 1:3710 PONTOON RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4264
Practice Address - Country:US
Practice Address - Phone:618-931-2322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0153531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice