Provider Demographics
NPI:1366631798
Name:MARCONNIT, JOHN PETER (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PETER
Last Name:MARCONNIT
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:PO BOX 170
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:MI
Mailing Address - Zip Code:49756-0170
Mailing Address - Country:US
Mailing Address - Phone:989-786-2104
Mailing Address - Fax:
Practice Address - Street 1:3051 BAY STREET
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:MI
Practice Address - Zip Code:49756
Practice Address - Country:US
Practice Address - Phone:989-786-2104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI13005122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist