MEDICARE: DR. JOHN W. CONNELLY D.D.S

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	122300000X	Dentist	5001651	WI

General Provider Information

NPI Number	:	1972505071
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN W. CONNELLY D.D.S

Provider Business Mailing Address
First Line	:	270 N MAIN ST
Second Line	:
City	:	CLINTONVILLE
State	:	WI
Zip	:	54929-1104
Country	:	US
Telephone Number	:	715-823-6777
Fax Number	:

Provider Business Practice Location Address
First Line	:	270 N MAIN ST
Second Line	:
City	:	CLINTONVILLE
State	:	WI
Zip	:	54929-1104
Country	:	US
Telephone Number	:	715-823-6777
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2005
Last Update Date	:	07/08/2007

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