Provider Demographics
NPI:1124590179
Name:CONNELL-GENTLE, MFON-ABASI (RDH, PHDHP)
Entity Type:Individual
Prefix:
First Name:MFON-ABASI
Middle Name:
Last Name:CONNELL-GENTLE
Suffix:
Gender:F
Credentials:RDH, PHDHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 HAVERFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-1401
Mailing Address - Country:US
Mailing Address - Phone:215-471-2761
Mailing Address - Fax:
Practice Address - Street 1:5201 HAVERFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-1401
Practice Address - Country:US
Practice Address - Phone:215-471-2761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-31
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPHDH001055124Q00000X
NY032135124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist