Provider Demographics
NPI:1053396259
Name:CONNOLLY, MARK L (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
Last Name:CONNOLLY
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 1:411 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3610
Mailing Address - Country:US
Mailing Address - Phone:781-396-7707
Mailing Address - Fax:781-395-5035
Practice Address - Street 1:411 HIGH ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3610
Practice Address - Country:US
Practice Address - Phone:781-396-7707
Practice Address - Fax:781-395-5035
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA135501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice