Provider Demographics
NPI:1396813820
Name:CONNOLLY, JOHN L (DDS)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:L
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720
Mailing Address - Country:US
Mailing Address - Phone:218-879-6703
Mailing Address - Fax:218-879-7029
Practice Address - Street 1:1600 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720
Practice Address - Country:US
Practice Address - Phone:218-879-6703
Practice Address - Fax:218-499-8033
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN82141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice