Basic Information
Provider Information | |||||||||
NPI: | 1699407288 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FENNELL | ||||||||
FirstName: | PATRICIA | ||||||||
MiddleName: | JEAN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RDH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FENNELL | ||||||||
OtherFirstName: | PATTIE | ||||||||
OtherMiddleName: | JEAN | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RDH | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 205 E UNIVERSITY AVE STE 200 | ||||||||
Address2: |   | ||||||||
City: | GEORGETOWN | ||||||||
State: | TX | ||||||||
PostalCode: | 786266821 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 205 E UNIVERSITY AVE STE 200 | ||||||||
Address2: |   | ||||||||
City: | GEORGETOWN | ||||||||
State: | TX | ||||||||
PostalCode: | 786266821 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8778005722 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2022 | ||||||||
LastUpdateDate: | 06/30/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X |   |   | Y |   | Dental Providers | Dental Hygienist |   |
No ID Information.