Provider Demographics
NPI:1528197969
Name:CONNELL, JOHN KEITH (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KEITH
Last Name:CONNELL
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 1:1610 EDISON AVE
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661-2530
Mailing Address - Country:US
Mailing Address - Phone:256-383-5770
Mailing Address - Fax:
Practice Address - Street 1:1610 EDISON AVE
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661-2530
Practice Address - Country:US
Practice Address - Phone:256-383-5770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4083122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist