Healthcare Provider Details

I. General information

NPI: 1720012248
Provider Name (Legal Business Name): MICHAEL J CONLAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 BERGQUIST DR ATTN CREDENTIALS (CMC)
LACKLAND A F B TX
78236-9907
US

IV. Provider business mailing address

6126 WOOD PASS
SAN ANTONIO TX
78249-1933
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-2558
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2669
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: