Provider Demographics
NPI:1720201692
Name:CONNELLY, STEPHEN THADDEUS (MD,DDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:THADDEUS
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:MD,DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 TUOLUMNE RD
Mailing Address - Street 2:
Mailing Address - City:MILLBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94030-1536
Mailing Address - Country:US
Mailing Address - Phone:415-385-0665
Mailing Address - Fax:
Practice Address - Street 1:4150 CLEMENT ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94121-1545
Practice Address - Country:US
Practice Address - Phone:415-476-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA950421223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery