Healthcare Provider Details

I. General information

NPI: 1811816176
Provider Name (Legal Business Name): BRENDAN CONNOLLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5756 PACIFIC AVE
STOCKTON CA
95207-5160
US

IV. Provider business mailing address

600 HARTZ AVE UNIT 113
DANVILLE CA
94526-3975
US

V. Phone/Fax

Practice location:
  • Phone: 209-701-3171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113441
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: