Healthcare Provider Details

I. General information

NPI: 1306971882
Provider Name (Legal Business Name): SHAWN CONRAD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7320 MARKET ST
WILMINGTON NC
28411-9881
US

IV. Provider business mailing address

7320 MARKET ST
WILMINGTON NC
28411-9881
US

V. Phone/Fax

Practice location:
  • Phone: 910-386-5003
  • Fax: 910-681-1184
Mailing address:
  • Phone: 910-386-5003
  • Fax: 910-681-1184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6326
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: