Provider Demographics
NPI:1356933840
Name:BELNAP, CONNER
Entity type:Individual
Prefix:
First Name:CONNER
Middle Name:
Last Name:BELNAP
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 1:965 S 100 W STE 100
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-6063
Mailing Address - Country:US
Mailing Address - Phone:435-752-7953
Mailing Address - Fax:
Practice Address - Street 1:965 SOUTH 100 WEST STE 100
Practice Address - Street 2:965 SOUTH 100 WEST STE 100
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321
Practice Address - Country:US
Practice Address - Phone:435-752-7953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-06
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLL-550-211223G0001X
390200000X
UT13633560-99261223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program