Provider Demographics
NPI:1619062080
Name:VELICK, KENNETH ALAN (DDS)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALAN
Last Name:VELICK
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 1:28793 APPLEBLOSSOM
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331
Mailing Address - Country:US
Mailing Address - Phone:248-489-1962
Mailing Address - Fax:
Practice Address - Street 1:2350 STONEBRIDGE DR
Practice Address - Street 2:BUILDING H
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532
Practice Address - Country:US
Practice Address - Phone:810-230-9091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI130111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2597927Medicaid