Provider Demographics
NPI:1124049119
Name:MCCONNELL, THOMASON MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMASON
Middle Name:MICHAEL
Last Name:MCCONNELL
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 1:1200 W 4TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-5013
Mailing Address - Country:US
Mailing Address - Phone:918-458-9100
Mailing Address - Fax:918-458-9200
Practice Address - Street 1:1200 W 4TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5013
Practice Address - Country:US
Practice Address - Phone:918-458-9100
Practice Address - Fax:918-458-9200
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK52671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA214781OtherBC/BS OF VIRGINIA
PA814714OtherUNITED CONCORDIA