Provider Demographics
NPI:1518422294
Name:FENNELL, BRITTANY
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:FENNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 STARRATT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-1330
Mailing Address - Country:US
Mailing Address - Phone:903-530-0205
Mailing Address - Fax:
Practice Address - Street 1:13201 NEW BERLIN RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32226
Practice Address - Country:US
Practice Address - Phone:909-047-5375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1223000001223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health