Provider Demographics
NPI:1851656375
Name:FLEAGLE, JENELLE LOUISE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENELLE
Middle Name:LOUISE
Last Name:FLEAGLE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5509 BENDT DR STE 302
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-9460
Mailing Address - Country:US
Mailing Address - Phone:605-939-7992
Mailing Address - Fax:605-534-1599
Practice Address - Street 1:5509 BENDT DR STE 302
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-9460
Practice Address - Country:US
Practice Address - Phone:605-939-7992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD13241223P0221X
OH30-023733122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0098381Medicaid