Basic Information
| Provider Information | |||||||||
| NPI: | 1194090175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONKLIN | ||||||||
| FirstName: | ANTON | ||||||||
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| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5201 WALZEM RD | ||||||||
| Address2: | |||||||||
| City: | WINDCREST | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782182122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105030000 | ||||||||
| FaxNumber: | 2815336130 | ||||||||
| Practice Location | |||||||||
| Address1: | 1113 PROGRESS DR | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975045201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415123900 | ||||||||
| FaxNumber: | 5415121026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2012 | ||||||||
| LastUpdateDate: | 05/11/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 122300000X | D9787 | OR | N | Dental Providers | Dentist | 1223G0001X | 31423 | TX | Y | Dental Providers | Dentist | General Practice |
No ID Information.