Provider Demographics
NPI:1235187501
Name:MCCONNELL, TIMOTHY IVAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:IVAN
Last Name:MCCONNELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1120
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-1120
Mailing Address - Country:US
Mailing Address - Phone:843-553-5235
Mailing Address - Fax:843-797-8189
Practice Address - Street 1:100 BERKELEY SQUARE LN
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-2958
Practice Address - Country:US
Practice Address - Phone:843-553-5235
Practice Address - Fax:843-797-8189
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ17599Medicaid
SC79343OtherUNITED CONCORDIA INSURANC