=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407072648
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERICA SANDRA CONWAY DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 TRANCAS ST STE A
-----------------------------------------------------
City | NAPA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94558-3308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-226-7614
-----------------------------------------------------
Fax | 707-226-2478
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 TRANCAS ST STE A
-----------------------------------------------------
City | NAPA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94558-3308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-226-7614
-----------------------------------------------------
Fax | 707-226-2478
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 42989
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------