Provider Demographics
NPI:1114014503
Name:FELLNER, JEFFREY E (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:E
Last Name:FELLNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20265 N 59TH AVE
Mailing Address - Street 2:SUITE B-5
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6819
Mailing Address - Country:US
Mailing Address - Phone:623-362-9616
Mailing Address - Fax:623-362-2614
Practice Address - Street 1:20265 N 59TH AVE
Practice Address - Street 2:SUITE B-5
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6819
Practice Address - Country:US
Practice Address - Phone:623-362-9616
Practice Address - Fax:623-362-2614
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ44331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice