Provider Demographics
NPI:1891004503
Name:CONNER, JOHN DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:CONNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1146 N. CASS STREET
Mailing Address - Street 2:SUITE C
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-1836
Mailing Address - Country:US
Mailing Address - Phone:260-563-4805
Mailing Address - Fax:260-563-2958
Practice Address - Street 1:1146 N. CASS STREET
Practice Address - Street 2:SUITE C
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-1836
Practice Address - Country:US
Practice Address - Phone:260-563-4805
Practice Address - Fax:260-563-2958
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011312A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist