Provider Demographics
NPI:1679149512
Name:CONROY, SAMANTHA (DDS)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:
Last Name:CONROY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:BORNAMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:400 N PARK AVE
Mailing Address - Street 2:#12B
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80424
Mailing Address - Country:US
Mailing Address - Phone:816-456-1155
Mailing Address - Fax:
Practice Address - Street 1:235 S. RIDGE ST.
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:CO
Practice Address - Zip Code:80423
Practice Address - Country:US
Practice Address - Phone:970-453-4244
Practice Address - Fax:970-360-2683
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20210195001223G0001X, 122300000X
CODEN.002056981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist