Provider Demographics
NPI:1134282007
Name:CONRAD, JOHANNA (DDS)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:CONRAD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3189
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-3189
Mailing Address - Country:US
Mailing Address - Phone:315-454-6000
Mailing Address - Fax:315-454-8650
Practice Address - Street 1:730 BROAD ST
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-2381
Practice Address - Country:US
Practice Address - Phone:330-336-6590
Practice Address - Fax:330-336-0222
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21877122300000X
OH30-021877122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist