Provider Demographics
NPI:1295090140
Name:DONNELLY, DAVID EUGENE (DDS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:EUGENE
Last Name:DONNELLY
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 1:4972 DAYTON LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-5946
Mailing Address - Country:US
Mailing Address - Phone:937-287-7201
Mailing Address - Fax:
Practice Address - Street 1:4972 DAYTON LIBERTY RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-5946
Practice Address - Country:US
Practice Address - Phone:937-287-7201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-06
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH 18700122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist