MEDICARE: MICHAEL L CONNOLLY DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	019020342	IL

General Provider Information

NPI Number	:	1366969495
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL L CONNOLLY DDS

Provider Business Mailing Address
First Line	:	6019 N CICERO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-4301
Country	:	US
Telephone Number	:	773-286-9700
Fax Number	:

Provider Business Practice Location Address
First Line	:	6019 N CICERO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-4301
Country	:	US
Telephone Number	:	773-286-9700
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHAEL L CONNOLLY
Credential	:	DDS
Telephone Number	:	773-286-9700

Provider Enumeration Date	:	08/29/2017
Last Update Date	:	08/29/2017

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