Provider Demographics
NPI:1831384270
Name:MCDONNELL, GERALD R (DDS)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:R
Last Name:MCDONNELL
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 1:1576 W BLUEWATER HWY
Mailing Address - Street 2:
Mailing Address - City:IONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48846-8594
Mailing Address - Country:US
Mailing Address - Phone:616-527-6331
Mailing Address - Fax:616-527-2883
Practice Address - Street 1:1576 W BLUEWATER HWY
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-8594
Practice Address - Country:US
Practice Address - Phone:616-527-6331
Practice Address - Fax:616-527-2883
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI8954122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist