Provider Demographics
NPI:1518033562
Name:CONNELL, EVAN K (DDS)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:K
Last Name:CONNELL
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 820
Mailing Address - Street 2:
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020
Mailing Address - Country:US
Mailing Address - Phone:573-346-7278
Mailing Address - Fax:573-346-2176
Practice Address - Street 1:1497 N HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020
Practice Address - Country:US
Practice Address - Phone:573-346-7278
Practice Address - Fax:573-346-2716
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20010138731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice