Healthcare Provider Details

I. General information

NPI: 1063638971
Provider Name (Legal Business Name): TIMOTHY WAYNE CONLEY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 01/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5188 WINTON RD
FAIRFIELD OH
45014-2900
US

IV. Provider business mailing address

8365 JEANETTE LN
CINCINNATI OH
45249-2369
US

V. Phone/Fax

Practice location:
  • Phone: 513-829-8080
  • Fax:
Mailing address:
  • Phone: 513-469-2827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number19071
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: