Healthcare Provider Details

I. General information

NPI: 1992931000
Provider Name (Legal Business Name): CHAUNCEY L. CONNER DDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2009
Last Update Date: 06/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 BARRETT PKWY SUITE 13
KENNESAW GA
30144-7557
US

IV. Provider business mailing address

1200 BARRETT PARKWAY SUITE 13
KENNESAW GA
30144
US

V. Phone/Fax

Practice location:
  • Phone: 678-354-0079
  • Fax: 678-354-0062
Mailing address:
  • Phone: 678-354-0079
  • Fax: 678-354-0062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: MS. MAYDEE SALGUERO
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 678-354-0079