=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457248890
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONOVER DENTAL CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2025
-----------------------------------------------------
Last Update Date | 06/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 WALNUT ST STE 1101
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19102-2907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-567-0521
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1601 WALNUT ST STE 1101
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19102-2907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-772-3100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DEREK JOHN CONOVER
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 908-461-1355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------