Provider Demographics
NPI:1881171577
Name:PAYNE, CONLEY (DDS)
Entity type:Individual
Prefix:
First Name:CONLEY
Middle Name:
Last Name:PAYNE
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 1:1954 TROSPER RD SW APT N201
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-8133
Mailing Address - Country:US
Mailing Address - Phone:808-226-9299
Mailing Address - Fax:
Practice Address - Street 1:1205 HARRISON AVE NW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5494
Practice Address - Country:US
Practice Address - Phone:360-352-4008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60874696122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist