MEDICARE: CONWAY DDS INC.

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

General Provider Information

NPI Number	:	1659095412
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONWAY DDS INC.

Provider Business Mailing Address
First Line	:	PO BOX 501265
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92150-1265
Country	:	US
Telephone Number	:	619-807-8710
Fax Number	:	619-474-4948

Provider Business Practice Location Address
First Line	:	9750 MIRAMAR RD STE 100
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-4561
Country	:	US
Telephone Number	:	858-271-7440
Fax Number	:	858-271-0180

Authorized Official
Title or Position	:	CEO
Name	:	DR. RAIVYN CONWAY
Credential	:	DDS
Telephone Number	:	619-477-1184

Provider Enumeration Date	:	09/26/2022
Last Update Date	:	09/26/2022

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