Healthcare Provider Details

I. General information

NPI: 1730815309
Provider Name (Legal Business Name): CONNER JERRY NIELSEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N FRESNO ST
FRESNO CA
93701-2302
US

IV. Provider business mailing address

11028 CAMPUS ST
LOMA LINDA CA
92354-2705
US

V. Phone/Fax

Practice location:
  • Phone: 559-459-4182
  • Fax:
Mailing address:
  • Phone: 714-788-6690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number107665
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number107665
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: