Provider Demographics
NPI:1154855666
Name:O'CONNELL, MICHELLE (LDA)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:LDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9950 VALLEY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4883
Mailing Address - Country:US
Mailing Address - Phone:651-578-7000
Mailing Address - Fax:
Practice Address - Street 1:9950 VALLEY CREEK RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4883
Practice Address - Country:US
Practice Address - Phone:651-578-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9106126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant