Provider Demographics
NPI:1366735557
Name:CONNELLY, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3847 GARDENVIEW PL
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-4516
Mailing Address - Country:US
Mailing Address - Phone:937-671-4315
Mailing Address - Fax:
Practice Address - Street 1:369 W 1ST ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-3095
Practice Address - Country:US
Practice Address - Phone:937-496-2620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist