Provider Demographics
NPI:1114583580
Name:LUTTRELL, CONNOR MADISON (DDS)
Entity Type:Individual
Prefix:DR
First Name:CONNOR
Middle Name:MADISON
Last Name:LUTTRELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 MDG, UNIT 3215
Mailing Address - Street 2:
Mailing Address - City:RAMSTEIN AB
Mailing Address - State:GERMANY
Mailing Address - Zip Code:67686
Mailing Address - Country:DE
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:86 MDG, UNIT 3215
Practice Address - Street 2:
Practice Address - City:RAMSTEIN AB
Practice Address - State:GERMANY
Practice Address - Zip Code:67686
Practice Address - Country:DE
Practice Address - Phone:817-975-8959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-11
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX356541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program