Healthcare Provider Details

I. General information

NPI: 1356577704
Provider Name (Legal Business Name): JAY CHARLES MCCONNELL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2009
Last Update Date: 12/22/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7001 A ST STE 101
LINCOLN NE
68510-4205
US

IV. Provider business mailing address

7001 A ST STE 101
LINCOLN NE
68510-4205
US

V. Phone/Fax

Practice location:
  • Phone: 402-486-3630
  • Fax: 402-486-3637
Mailing address:
  • Phone: 402-486-3630
  • Fax: 402-486-3637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number6367
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: