Provider Demographics
NPI:1952410565
Name:CONKLIN & DOERSCH DDS INC
Entity type:Organization
Organization Name:CONKLIN & DOERSCH DDS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-436-6007
Mailing Address - Street 1:8 WYOMING ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WELCH
Mailing Address - State:WV
Mailing Address - Zip Code:24801-2429
Mailing Address - Country:US
Mailing Address - Phone:304-436-6007
Mailing Address - Fax:304-436-6009
Practice Address - Street 1:8 WYOMING ST
Practice Address - Street 2:STE 301
Practice Address - City:WELCH
Practice Address - State:WV
Practice Address - Zip Code:24801-2429
Practice Address - Country:US
Practice Address - Phone:304-436-6007
Practice Address - Fax:304-436-6009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810003513Medicaid