Healthcare Provider Details

I. General information

NPI: 1891801957
Provider Name (Legal Business Name): J DENNIS CONNOR DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 FOND DU LAC AVE
KEWASKUM WI
53040-8954
US

IV. Provider business mailing address

PO BOX 66
KEWASKUM WI
53040-0066
US

V. Phone/Fax

Practice location:
  • Phone: 262-626-2119
  • Fax: 262-626-2110
Mailing address:
  • Phone: 262-626-2119
  • Fax: 262-626-2110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: