Provider Demographics
NPI:1972505071
Name:CONNELLY, JOHN W (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLINTONVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54929-1104
Mailing Address - Country:US
Mailing Address - Phone:715-823-6777
Mailing Address - Fax:
Practice Address - Street 1:270 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54929-1104
Practice Address - Country:US
Practice Address - Phone:715-823-6777
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001651122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist