Provider Demographics
NPI:1245215128
Name:CONNOLLY, DENNIS M (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:M
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 35TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-5119
Mailing Address - Country:US
Mailing Address - Phone:262-658-3488
Mailing Address - Fax:262-658-3433
Practice Address - Street 1:2901 35TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-5119
Practice Address - Country:US
Practice Address - Phone:262-658-3488
Practice Address - Fax:262-658-3433
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI500088941223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33366400Medicare ID - Type Unspecified