Healthcare Provider Details

I. General information

NPI: 1245215128
Provider Name (Legal Business Name): DENNIS M CONNOLLY DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 35TH ST
KENOSHA WI
53140-5119
US

IV. Provider business mailing address

2901 35TH ST
KENOSHA WI
53140-5119
US

V. Phone/Fax

Practice location:
  • Phone: 262-658-3488
  • Fax: 262-658-3433
Mailing address:
  • Phone: 262-658-3488
  • Fax: 262-658-3433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number50008894
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: