Provider Demographics
NPI:1922137546
Name:CONNOLLY, CAROLINE (DMD)
Entity Type:Individual
Prefix:DR
First Name:CAROLINE
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 N GREEN MOUNT RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3416
Mailing Address - Country:US
Mailing Address - Phone:618-632-1603
Mailing Address - Fax:618-632-6034
Practice Address - Street 1:1490 N GREEN MOUNT RD
Practice Address - Street 2:SUITE B
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-3416
Practice Address - Country:US
Practice Address - Phone:618-632-1603
Practice Address - Fax:618-632-6034
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1005523Medicaid