Basic Information
| Provider Information | |||||||||
| NPI: | 1306092804 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCONNELL | ||||||||
| FirstName: | MINDY | ||||||||
| MiddleName: | MARGARETE MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 10205 N RIVA RIDGE LOOP | ||||||||
| Address2: | |||||||||
| City: | FORT DRUM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136025457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157728891 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10205 N RIVA RIDGE LOOP | ||||||||
| Address2: | |||||||||
| City: | FORT DRUM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136025457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157728891 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2008 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 6063 | OK | N | Dental Providers | Dentist | General Practice | 122300000X | 6063 | OK | Y | Dental Providers | Dentist |
No ID Information.