Provider Demographics
NPI:1669574323
Name:CONNELLEY, RICHARD L (DMD)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:L
Last Name:CONNELLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:853 S MAYO TRL
Mailing Address - Street 2:
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240-1215
Mailing Address - Country:US
Mailing Address - Phone:606-789-7694
Mailing Address - Fax:606-789-7708
Practice Address - Street 1:853 S MAYO TRL
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240-1215
Practice Address - Country:US
Practice Address - Phone:606-789-7694
Practice Address - Fax:606-789-7708
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY50781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60050788Medicaid