Provider Demographics
NPI:1104000819
Name:DONNELLY, PATRICK F (DMD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:F
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:BRIELLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08730-1813
Mailing Address - Country:US
Mailing Address - Phone:732-528-8181
Mailing Address - Fax:732-528-5228
Practice Address - Street 1:105 UNION AVE
Practice Address - Street 2:
Practice Address - City:BRIELLE
Practice Address - State:NJ
Practice Address - Zip Code:08730-1813
Practice Address - Country:US
Practice Address - Phone:732-528-8181
Practice Address - Fax:732-528-5228
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI017262122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist