1750395166 NPI number — THOMAS WILLIAM CONNOLLY DMD

Table of content: THOMAS WILLIAM CONNOLLY DMD (NPI 1750395166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750395166 NPI number — THOMAS WILLIAM CONNOLLY DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONNOLLY
Provider First Name:
THOMAS
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750395166
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
118 TILLEY DRIVE
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
SOUTH BURLINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05403-7282
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-862-9196
Provider Business Mailing Address Fax Number:
802-862-5769

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
118 TILLEY DRIVE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
SOUTH BURLINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05403-7282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-862-9196
Provider Business Practice Location Address Fax Number:
802-862-5769
Provider Enumeration Date:
07/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  0160000786 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2412 . This is a "BLUE CROSS" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 2412 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 97V003 . This is a "MVP" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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