Provider Demographics
NPI:1881789824
Name:CONNELLY, KEVIN M (DMD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:CONNELLY
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 1:1065 LISBON ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5749
Mailing Address - Country:US
Mailing Address - Phone:207-376-4977
Mailing Address - Fax:207-376-4979
Practice Address - Street 1:1065 LISBON ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5749
Practice Address - Country:US
Practice Address - Phone:207-376-4977
Practice Address - Fax:207-376-4979
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME36191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice