Kelly Michelle Fenn, DDS, MSD

Primary specialty

Orthodontics and Dentofacial Orthopedics DentistryTaxonomy code 1223X0400X

License

2901600792 Issued in MI

Practice address

64845 Van Dyke Rd
Washington, MI 48095-2836

Phone

(586) 752-3504

NPI assigned

Jan 5, 2021

Last updated

Dec 18, 2024By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1609804800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1734480000000",
    "number": "1144818212",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "54557 JEFFERY DR",
            "city": "MACOMB",
            "state": "MI",
            "postal_code": "480425815",
            "telephone_number": "586-419-2064"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "64845 VAN DYKE RD",
            "city": "WASHINGTON",
            "state": "MI",
            "postal_code": "480952836",
            "telephone_number": "586-752-3504"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FENN",
        "first_name": "KELLY",
        "middle_name": "MICHELLE",
        "credential": "DDS, MSD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2021-01-05",
        "last_updated": "2024-12-18",
        "certification_date": "2024-12-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "MI",
            "license": "2901600792",
            "primary": false
        },
        {
            "code": "1223X0400X",
            "taxonomy_group": "",
            "desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
            "state": "MI",
            "license": "2901600792",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Orthodontics and Dentofacial Orthopedics Dentistry in Washington, MI
• Providers in Washington, MI by specialty
• Orthodontics and Dentofacial Orthopedics Dentistry in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 18, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.