MEDICARE: CYNTHIA JEAN CONVERSE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	7641	IA

General Provider Information

NPI Number	:	1356408843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CYNTHIA JEAN CONVERSE DDS

Provider Business Mailing Address
First Line	:	2138 CHAEL DRIVE NE
Second Line	:
City	:	SOLON
State	:	IA
Zip	:	52333-9215
Country	:	US
Telephone Number	:	319-624-3190
Fax Number	:	319-624-3502

Provider Business Practice Location Address
First Line	:	1101 5TH STREET
Second Line	:	SUITE 101
City	:	CORALVILLE
State	:	IA
Zip	:	52241-2904
Country	:	US
Telephone Number	:	319-337-9996
Fax Number	:	319-688-9996

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	07/08/2007

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