=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801655857
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CONNOR MCGOWAN DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2024
-----------------------------------------------------
Last Update Date | 10/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 212 NE 2ND ST APT 201
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73104-4069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-559-7265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6680 DAVIS RD
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42003-9382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-559-7265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 7911
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------