Healthcare Provider Details

I. General information

NPI: 1396972501
Provider Name (Legal Business Name): BENJAMIN JEFFREY CONNOR D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2009
Last Update Date: 01/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 E 5TH ST SUITE 200
WASHINGTON MO
63090-3135
US

IV. Provider business mailing address

PO BOX 502852
SAINT LOUIS MO
63150-2852
US

V. Phone/Fax

Practice location:
  • Phone: 636-239-8585
  • Fax: 636-239-8553
Mailing address:
  • Phone: 636-239-8585
  • Fax: 636-239-8553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number2009013175
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: