Provider Demographics
NPI:1467462788
Name:FELL, JEANINE MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEANINE
Middle Name:MARIE
Last Name:FELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 SOUTH VANBUREN
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:IL
Mailing Address - Zip Code:62448
Mailing Address - Country:US
Mailing Address - Phone:618-783-3714
Mailing Address - Fax:618-783-3294
Practice Address - Street 1:605 SOUTH VANBUREN
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:IL
Practice Address - Zip Code:62448
Practice Address - Country:US
Practice Address - Phone:618-783-3714
Practice Address - Fax:618-783-3294
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019020343122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1002281Medicaid