Provider Demographics
NPI:1659513950
Name:CONNELL, MELISSA MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:MARIE
Last Name:CONNELL
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 1:2045 W CONCORD PL
Mailing Address - Street 2:#504
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5628
Mailing Address - Country:US
Mailing Address - Phone:312-848-2282
Mailing Address - Fax:
Practice Address - Street 1:1611 WOLCOTT AVE.
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622
Practice Address - Country:US
Practice Address - Phone:312-848-2282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0257111223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry