Provider Demographics
NPI:1861469777
Name:CONNELL, CHARLES RICHARD (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:RICHARD
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 1:900 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-2001
Mailing Address - Country:US
Mailing Address - Phone:870-733-6331
Mailing Address - Fax:870-732-1940
Practice Address - Street 1:900 N 7TH ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-2001
Practice Address - Country:US
Practice Address - Phone:870-733-6388
Practice Address - Fax:870-732-1940
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2311122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101970608Medicaid