Provider Demographics
NPI:1144818212
Name:FENN, KELLY MICHELLE (DDS, MSD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELLE
Last Name:FENN
Suffix:
Gender:F
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54557 JEFFERY DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-5815
Mailing Address - Country:US
Mailing Address - Phone:586-419-2064
Mailing Address - Fax:
Practice Address - Street 1:64845 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MI
Practice Address - Zip Code:48095-2836
Practice Address - Country:US
Practice Address - Phone:586-752-3504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901600792122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist