Healthcare Provider Details

I. General information

NPI: 1679149512
Provider Name (Legal Business Name): SAMANTHA CONROY D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SAMANTHA BORNAMAN D.D.S.

II. Dates (important events)

Enumeration Date: 06/01/2021
Last Update Date: 10/21/2024
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 S. RIDGE ST.
BRECKENRIDGE CO
80423
US

IV. Provider business mailing address

400 N PARK AVE #12B
BRECKENRIDGE CO
80424
US

V. Phone/Fax

Practice location:
  • Phone: 970-453-4244
  • Fax: 970-360-2683
Mailing address:
  • Phone: 816-456-1155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2021019500
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2021019500
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN.00205698
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: