Provider Demographics
NPI:1174748560
Name:CONWAY, THERESA BETH (DDS,MS)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:BETH
Last Name:CONWAY
Suffix:
Gender:F
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 ENGLISH IVY COURT
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080
Mailing Address - Country:US
Mailing Address - Phone:404-964-5511
Mailing Address - Fax:
Practice Address - Street 1:2302 ENGLISH IVY COURT
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080
Practice Address - Country:US
Practice Address - Phone:404-964-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0123671223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA012367OtherDENTAL LICENSE NUMBER