Provider Demographics
NPI:1598997868
Name:CONNOLLY, SEAN PATRICK (DMD)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:PATRICK
Last Name:CONNOLLY
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 1:1585 THIRD STREET
Mailing Address - Street 2:USA DENTAC
Mailing Address - City:FT POLK
Mailing Address - State:LA
Mailing Address - Zip Code:71446
Mailing Address - Country:US
Mailing Address - Phone:337-531-4762
Mailing Address - Fax:337-531-6506
Practice Address - Street 1:1585 THIRD STREET
Practice Address - Street 2:USA DENTAC
Practice Address - City:FT POLK
Practice Address - State:LA
Practice Address - Zip Code:71446
Practice Address - Country:US
Practice Address - Phone:337-531-4762
Practice Address - Fax:337-531-6506
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN-10015122300000X
CO100151223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist