Provider Demographics
NPI:1932411311
Name:L. MICHELLE CONNER DDS PA DBA BEACON DENTAL CENTER
Entity Type:Organization
Organization Name:L. MICHELLE CONNER DDS PA DBA BEACON DENTAL CENTER
Other - Org Name:BEACON DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LILLIAN
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:CONNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-527-1228
Mailing Address - Street 1:4805 PARK RD
Mailing Address - Street 2:#223
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3803
Mailing Address - Country:US
Mailing Address - Phone:704-527-1228
Mailing Address - Fax:
Practice Address - Street 1:4805 PARK RD
Practice Address - Street 2:#223
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3803
Practice Address - Country:US
Practice Address - Phone:704-527-1228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-13
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND6133261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89902A2Medicaid