Provider Demographics
NPI:1366748105
Name:MICHAEL CONWAY DDS PLLC
Entity type:Organization
Organization Name:MICHAEL CONWAY DDS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERI
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:SHACKELFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-485-0588
Mailing Address - Street 1:5723 NE BOTHELL WAY STE B
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028-9404
Mailing Address - Country:US
Mailing Address - Phone:425-485-0588
Mailing Address - Fax:425-483-6189
Practice Address - Street 1:5723 NE BOTHELL WAY STE B
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:WA
Practice Address - Zip Code:98028-9404
Practice Address - Country:US
Practice Address - Phone:425-485-0588
Practice Address - Fax:425-483-6189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-26
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA74961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7526610001Medicare NSC