Provider Demographics
NPI:1154483576
Name:CONNELL, JUDSON T (DMDM)
Entity Type:Individual
Prefix:MR
First Name:JUDSON
Middle Name:T
Last Name:CONNELL
Suffix:
Gender:M
Credentials:DMDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3895 JOHNS CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1295
Mailing Address - Country:US
Mailing Address - Phone:770-623-8877
Mailing Address - Fax:
Practice Address - Street 1:3895 JOHNS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1295
Practice Address - Country:US
Practice Address - Phone:770-623-8877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADO109931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice