Provider Demographics
NPI:1548320138
Name:CONWAY & CONWAY DDS PA
Entity type:Organization
Organization Name:CONWAY & CONWAY DDS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:C
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-569-4118
Mailing Address - Street 1:3755 7TH TERRACE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-6547
Mailing Address - Country:US
Mailing Address - Phone:772-569-4118
Mailing Address - Fax:772-569-9446
Practice Address - Street 1:3755 7TH TERRACE
Practice Address - Street 2:SUITE 303
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6547
Practice Address - Country:US
Practice Address - Phone:772-569-4118
Practice Address - Fax:772-569-9446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL93401223G0001X
FL193611223G0001X
FL84921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45777OtherBCBS CORP PROVIDER