Provider Demographics
NPI:1780032763
Name:CONNELL, MATTHEW EVAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:EVAN
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:65020-0820
Mailing Address - Country:US
Mailing Address - Phone:573-346-7278
Mailing Address - Fax:573-346-2176
Practice Address - Street 1:1497 N BUSINESS ROUTE 5
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-2636
Practice Address - Country:US
Practice Address - Phone:573-346-7278
Practice Address - Fax:573-346-2176
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016017394122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist