Provider Demographics
NPI:1891156816
Name:MA, CONWAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:CONWAY
Middle Name:
Last Name:MA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 JONES CT
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-6002
Mailing Address - Country:US
Mailing Address - Phone:860-822-3009
Mailing Address - Fax:
Practice Address - Street 1:12 GOOSE LN
Practice Address - Street 2:
Practice Address - City:TOLLAND
Practice Address - State:CT
Practice Address - Zip Code:06084-3400
Practice Address - Country:US
Practice Address - Phone:860-875-6269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-18
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18576871223G0001X
390200000X
CT133221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program