1932411311 NPI number — L. MICHELLE CONNER DDS PA DBA BEACON DENTAL CENTER

Table of content: DR. JUAN G. SOTO M.D. (NPI 1023159050)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932411311 NPI number — L. MICHELLE CONNER DDS PA DBA BEACON DENTAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
L. MICHELLE CONNER DDS PA DBA BEACON DENTAL CENTER
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:
1932411311
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4805 PARK RD
Provider Second Line Business Mailing Address:
#223
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28209-3803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-527-1228
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4805 PARK RD
Provider Second Line Business Practice Location Address:
#223
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28209-3803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-527-1228
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CONNER
Authorized Official First Name:
LILLIAN
Authorized Official Middle Name:
MICHELLE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
704-527-1228

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  6133 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 89902A2 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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