Provider Demographics
NPI:1750966925
Name:CONWAYDENTALCORP
Entity type:Organization
Organization Name:CONWAYDENTALCORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RAIVYN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CONWAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-475-4226
Mailing Address - Street 1:4190 BONITA RD STE 205
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-1340
Mailing Address - Country:US
Mailing Address - Phone:619-475-4226
Mailing Address - Fax:
Practice Address - Street 1:4190 BONITA RD STE 205
Practice Address - Street 2:
Practice Address - City:BONITA
Practice Address - State:CA
Practice Address - Zip Code:91902-1340
Practice Address - Country:US
Practice Address - Phone:619-475-4226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-10
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty