Provider Demographics
NPI:1174733588
Name:CONNOR, KEVIN JAMES (DDS, MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:JAMES
Last Name:CONNOR
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1111 DELAFIELD STREET
Mailing Address - Street 2:SUITE 222
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3403
Mailing Address - Country:US
Mailing Address - Phone:262-547-8665
Mailing Address - Fax:262-547-8685
Practice Address - Street 1:1111 DELAFIELD STREET
Practice Address - Street 2:SUITE 222
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3403
Practice Address - Country:US
Practice Address - Phone:262-547-8665
Practice Address - Fax:262-547-8685
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAS-406204E00000X
WI6201 546301223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA07054Medicaid