Provider Demographics
NPI:1528801081
Name:FOMENKO, KENEDY (DMD)
Entity type:Individual
Prefix:
First Name:KENEDY
Middle Name:
Last Name:FOMENKO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1896 LIGHTHOUSE LN
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49696-9302
Mailing Address - Country:US
Mailing Address - Phone:989-280-0602
Mailing Address - Fax:
Practice Address - Street 1:205 GROVE ST
Practice Address - Street 2:
Practice Address - City:MANCELONA
Practice Address - State:MI
Practice Address - Zip Code:49659-8018
Practice Address - Country:US
Practice Address - Phone:866-878-6553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016022621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice