Healthcare Provider Details

I. General information

NPI: 1801655857
Provider Name (Legal Business Name): CONNOR MCGOWAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2024
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 NE 2ND ST APT 201
OKLAHOMA CITY OK
73104-4069
US

IV. Provider business mailing address

6680 DAVIS RD
PADUCAH KY
42003-9382
US

V. Phone/Fax

Practice location:
  • Phone: 270-559-7265
  • Fax:
Mailing address:
  • Phone: 270-559-7265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7911
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: