Provider Demographics
NPI:1558800409
Name:MCCONNEL, THOMAS P
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:P
Last Name:MCCONNEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6113 LAKESIDE AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23228-5236
Mailing Address - Country:US
Mailing Address - Phone:804-262-9824
Mailing Address - Fax:
Practice Address - Street 1:6113 LAKESIDE AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-5236
Practice Address - Country:US
Practice Address - Phone:804-262-9824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0401418030122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program