Provider Demographics
NPI:1720248248
Name:CONWAY VILLAGE DENTAL PLLC
Entity Type:Organization
Organization Name:CONWAY VILLAGE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:603-447-6707
Mailing Address - Street 1:7 GREENWOOD AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03818-6130
Mailing Address - Country:US
Mailing Address - Phone:603-447-6707
Mailing Address - Fax:603-447-8376
Practice Address - Street 1:7 GREENWOOD AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03818-6130
Practice Address - Country:US
Practice Address - Phone:603-447-6707
Practice Address - Fax:603-447-8376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME139600000Medicaid
NH99002725Medicaid