1568569416 NPI number — KATHERINE V. CONWAY D.D.S. P. A

Table of content: (NPI 1568569416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568569416 NPI number — KATHERINE V. CONWAY D.D.S. P. A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KATHERINE V. CONWAY D.D.S. P. A
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568569416
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
955 HIGHWAY 55
Provider Second Line Business Mailing Address:
SUITE 6
Provider Business Mailing Address City Name:
HASTINGS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55033-2365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-437-9764
Provider Business Mailing Address Fax Number:
651-438-3138

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
955 HIGHWAY 55
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
HASTINGS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55033-2365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-437-9764
Provider Business Practice Location Address Fax Number:
651-438-3138
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CONWAY
Authorized Official First Name:
KATHERINE
Authorized Official Middle Name:
VERONICA
Authorized Official Title or Position:
GENERAL DENTIST
Authorized Official Telephone Number:
651-437-9764

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  10148 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000724372 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 513823000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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