Provider Demographics
NPI:1457972002
Name:MCCONNELL, LYDIA R (RDH)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:R
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2435 E WILLAMETTE AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-4840
Mailing Address - Country:US
Mailing Address - Phone:717-836-0541
Mailing Address - Fax:
Practice Address - Street 1:3715 BLOOMINGTON ST UNIT 160
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-3207
Practice Address - Country:US
Practice Address - Phone:717-836-0541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH.002024794124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist