Provider Demographics
NPI:1689043192
Name:SHELIA Y KENNEBREW DDS., MS., PC
Entity Type:Organization
Organization Name:SHELIA Y KENNEBREW DDS., MS., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELIA
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:KENNEBREW HORTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:248-552-1195
Mailing Address - Street 1:29556 SOUTHFIELD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2021
Mailing Address - Country:US
Mailing Address - Phone:248-552-1195
Mailing Address - Fax:248-552-0980
Practice Address - Street 1:29556 SOUTHFIELD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2021
Practice Address - Country:US
Practice Address - Phone:248-552-1195
Practice Address - Fax:248-552-0980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID29010152961223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty