Healthcare Provider Details

I. General information

NPI: 1821071341
Provider Name (Legal Business Name): TIMOTHY P MCCONNELL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1858 CREST RD
MARYVILLE TN
37804-4305
US

IV. Provider business mailing address

1858 CREST RD
MARYVILLE TN
37804-4305
US

V. Phone/Fax

Practice location:
  • Phone: 865-977-7110
  • Fax: 865-977-4132
Mailing address:
  • Phone: 865-977-7110
  • Fax: 865-977-4132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6806
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: