Provider Demographics
NPI:1336648393
Name:KENWAY, RAEDEANE
Entity Type:Individual
Prefix:MRS
First Name:RAEDEANE
Middle Name:
Last Name:KENWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RAEDEANE
Other - Middle Name:
Other - Last Name:MACCIOMEI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8542 HOLLY RD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439
Mailing Address - Country:US
Mailing Address - Phone:810-603-7887
Mailing Address - Fax:810-720-1306
Practice Address - Street 1:8542 HOLLY RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439
Practice Address - Country:US
Practice Address - Phone:810-603-7887
Practice Address - Fax:810-720-1306
Is Sole Proprietor?:No
Enumeration Date:2018-02-06
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902008900124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist