=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508419342
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CONNOR MICHAEL MCCANE DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2019
-----------------------------------------------------
Last Update Date | 03/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 S CENTER ST
-----------------------------------------------------
City | SHERIDAN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48884-9301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-291-3302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8333 WOODCREST DR NE
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49341-8507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-340-6723
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2901600217
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------