Provider Demographics
NPI:1649381492
Name:CONKLIN, THOMAS LYNN (DDS)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:LYNN
Last Name:CONKLIN
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 1:415 MORRIS STREET, SUITE 304
Mailing Address - Street 2:INTEGRATED HEALTH CARE PROVIDERS, INC.
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301
Mailing Address - Country:US
Mailing Address - Phone:304-388-7782
Mailing Address - Fax:304-388-7788
Practice Address - Street 1:3200 MACCORKLE AVENUE SE
Practice Address - Street 2:DENTAL CENTER
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-388-9335
Practice Address - Fax:304-388-8882
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV 3233122300000X
WV32331223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO4245632Medicare PIN