Provider Demographics
NPI:1619141983
Name:MCCONNELL, NISSA N (DDS)
Entity Type:Individual
Prefix:
First Name:NISSA
Middle Name:N
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 N GREEN RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-2415
Mailing Address - Country:US
Mailing Address - Phone:812-476-3002
Mailing Address - Fax:812-476-3027
Practice Address - Street 1:731 N GREEN RIVER RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-2415
Practice Address - Country:US
Practice Address - Phone:812-476-3002
Practice Address - Fax:812-476-3027
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011723A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201030300Medicaid