Provider Demographics
NPI:1750395166
Name:CONNOLLY, THOMAS WILLIAM (DMD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:WILLIAM
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 1:118 TILLEY DRIVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7282
Mailing Address - Country:US
Mailing Address - Phone:802-862-9196
Mailing Address - Fax:802-862-5769
Practice Address - Street 1:118 TILLEY DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7282
Practice Address - Country:US
Practice Address - Phone:802-862-9196
Practice Address - Fax:802-862-5769
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT01600007861223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT2412OtherBLUE CROSS
VT2412Medicaid
VT97V003OtherMVP
VT2412OtherBLUE CROSS
T90615Medicare UPIN