1730290057 NPI number — DR. GREGORY NILES CONNOLLY DMD

Table of content: DR. GREGORY NILES CONNOLLY DMD (NPI 1730290057)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730290057 NPI number — DR. GREGORY NILES CONNOLLY DMD

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
CONNOLLY

Provider First Name:
GREGORY

Provider Middle Name:
NILES

Provider Name Prefix Text:
DR.

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:
1730290057

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
07/08/2007

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
399 COMMON ST

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
BELMONT

Provider Business Mailing Address State Name:
MA

Provider Business Mailing Address Postal Code:
02478

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
617-484-7496

Provider Business Mailing Address Fax Number:
617-484-3324

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
399 COMMON ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
BELMONT

Provider Business Practice Location Address State Name:
MA

Provider Business Practice Location Address Postal Code:
02478

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
617-484-7496

Provider Business Practice Location Address Fax Number:
617-484-3324

Provider Enumeration Date:
08/31/2006

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: 1223G0001X , with the licence number: 12634 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .