Provider Demographics
NPI:1457415135
Name:THOMAS E CONDRON DDS
Entity Type:Organization
Organization Name:THOMAS E CONDRON DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:CONDRON
Authorized Official - Suffix:IX
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-623-4984
Mailing Address - Street 1:234 COURT ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-2906
Mailing Address - Country:US
Mailing Address - Phone:304-623-4984
Mailing Address - Fax:304-623-2830
Practice Address - Street 1:234 COURT ST
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-2906
Practice Address - Country:US
Practice Address - Phone:304-623-4984
Practice Address - Fax:304-623-2830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV19631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0134914000Medicaid
WV0137302000Medicaid
WV03810005032Medicaid