Provider Demographics
NPI:1013090091
Name:CONNELL, TODD JOHN
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:JOHN
Last Name:CONNELL
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 1:17100 W NORTH AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4436
Mailing Address - Country:US
Mailing Address - Phone:262-786-7886
Mailing Address - Fax:
Practice Address - Street 1:17100 W NORTH AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4436
Practice Address - Country:US
Practice Address - Phone:262-786-7886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIA42851223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics