Provider Demographics
NPI:1285873687
Name:EVERSMILES PEDIATRIC DENTISTRY, PLLC
Entity type:Organization
Organization Name:EVERSMILES PEDIATRIC DENTISTRY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:CONRY
Authorized Official - Suffix:
Authorized Official - Credentials:BDSMS
Authorized Official - Phone:218-728-2117
Mailing Address - Street 1:4419 AIR BASE ROAD
Mailing Address - Street 2:
Mailing Address - City:HERMANTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55811-1847
Mailing Address - Country:US
Mailing Address - Phone:218-728-2117
Mailing Address - Fax:218-728-2700
Practice Address - Street 1:4419 AIR BASE ROAD
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-1847
Practice Address - Country:US
Practice Address - Phone:218-728-2117
Practice Address - Fax:218-728-2700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-10
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty