Provider Demographics
NPI:1881393650
Name:MCCONNELL, SAMUEL JONATHAN (DDS)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JONATHAN
Last Name:MCCONNELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:JONATHAN
Other - Last Name:MCCONNELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:1400 PELHAM PKWY S
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-1197
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 PELHAM PKWY S
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1197
Practice Address - Country:US
Practice Address - Phone:718-918-3419
Practice Address - Fax:718-918-6147
Is Sole Proprietor?:No
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program