Provider Demographics
NPI:1154579878
Name:MCCONNELL, KENT D (DMD)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:D
Last Name:MCCONNELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 SPOTSYLVANIA ST
Mailing Address - Street 2:
Mailing Address - City:NEW ATHENS
Mailing Address - State:IL
Mailing Address - Zip Code:62264-1597
Mailing Address - Country:US
Mailing Address - Phone:618-475-9989
Mailing Address - Fax:
Practice Address - Street 1:1002 SPOTSYLVANIA ST
Practice Address - Street 2:
Practice Address - City:NEW ATHENS
Practice Address - State:IL
Practice Address - Zip Code:62264-1597
Practice Address - Country:US
Practice Address - Phone:618-475-9989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0237301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice