Healthcare Provider Details

I. General information

NPI: 1629163456
Provider Name (Legal Business Name): MICHAEL JOSEPH CONNOLLY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393A RIVER RD
FAIR HAVEN NJ
07704-3029
US

IV. Provider business mailing address

393 RIVER RD
FAIR HAVEN NJ
07704-3029
US

V. Phone/Fax

Practice location:
  • Phone: 732-842-8014
  • Fax: 732-842-6551
Mailing address:
  • Phone: 732-842-2579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI01135100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: