Provider Demographics
NPI:1760920623
Name:CONNALLY, RONALD (DMD,MD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:
Last Name:CONNALLY
Suffix:
Gender:M
Credentials:DMD,MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:AL
Mailing Address - Zip Code:36559-0910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23845 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:AL
Practice Address - Zip Code:36559-0910
Practice Address - Country:US
Practice Address - Phone:251-375-1639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4360122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist