Provider Demographics
NPI:1891229761
Name:MAHONEY, CONNOR
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:MAHONEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 JANDELL CIRCLE NE
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:MN
Mailing Address - Zip Code:55376
Mailing Address - Country:US
Mailing Address - Phone:605-381-3963
Mailing Address - Fax:
Practice Address - Street 1:9281 CEDAR ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-4507
Practice Address - Country:US
Practice Address - Phone:612-361-5436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNS1861223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery