Provider Demographics
NPI:1629226568
Name:FELLERMAN, KENNETH GREGORY (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:GREGORY
Last Name:FELLERMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 EAST 210TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467
Mailing Address - Country:US
Mailing Address - Phone:718-547-8200
Mailing Address - Fax:718-547-6540
Practice Address - Street 1:55 EAST 210TH ST
Practice Address - Street 2:SUITE 1B
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-547-8200
Practice Address - Fax:718-547-6540
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033489122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist