Provider Demographics
NPI:1497890669
Name:CONNELLY, CHARLES EDMUND JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EDMUND
Last Name:CONNELLY
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:C
Other - Middle Name:EDMUND
Other - Last Name:CONNELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:406 LECOMPTE STREET
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613
Mailing Address - Country:US
Mailing Address - Phone:410-228-8770
Mailing Address - Fax:410-228-0598
Practice Address - Street 1:406 LECOMPTE STREET
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613
Practice Address - Country:US
Practice Address - Phone:410-228-8770
Practice Address - Fax:410-228-0598
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD47971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
2036OtherCARE FIRST BCBS