Provider Demographics
NPI:1043417504
Name:JENNINGS, MICHAEL D (DENTIST)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22601 HARPER AVE
Mailing Address - Street 2:SUITE 1003
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1829
Mailing Address - Country:US
Mailing Address - Phone:586-772-7393
Mailing Address - Fax:
Practice Address - Street 1:22601 HARPER AVE
Practice Address - Street 2:SUITE 1003
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1829
Practice Address - Country:US
Practice Address - Phone:586-772-7393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI11575122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist