Basic Information
| Provider Information | |||||||||
| NPI: | 1649381492 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONKLIN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 MORRIS STREET, SUITE 304 | ||||||||
| Address2: | INTEGRATED HEALTH CARE PROVIDERS, INC. | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043887782 | ||||||||
| FaxNumber: | 3043887788 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 MACCORKLE AVENUE SE | ||||||||
| Address2: | DENTAL CENTER | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043889335 | ||||||||
| FaxNumber: | 3043888882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/16/2010 | ||||||||
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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 | 122300000X | WV 3233 | WV | N | Dental Providers | Dentist | 1223G0001X | 3233 | WV | N | Dental Providers | Dentist | General Practice | 122300000X | 3233 | WV | Y | Dental Providers | Dentist |
No ID Information.