Provider Demographics
NPI:1811380751
Name:FISENKOVA, SONA
Entity Type:Individual
Prefix:
First Name:SONA
Middle Name:
Last Name:FISENKOVA
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 1:32905 W 12 MILE RD STE 140
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3343
Mailing Address - Country:US
Mailing Address - Phone:248-987-2879
Mailing Address - Fax:248-715-6367
Practice Address - Street 1:32905 W 12 MILE RD STE 140
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3343
Practice Address - Country:US
Practice Address - Phone:248-987-2879
Practice Address - Fax:248-715-6367
Is Sole Proprietor?:No
Enumeration Date:2015-03-17
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010214041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice