Provider Demographics
NPI:1902367584
Name:FLEMING, MARLA KETTY (DMD)
Entity Type:Individual
Prefix:MS
First Name:MARLA
Middle Name:KETTY
Last Name:FLEMING
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 UNION AVE SE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5428
Mailing Address - Country:US
Mailing Address - Phone:857-210-3146
Mailing Address - Fax:
Practice Address - Street 1:2064 BALDWIN ST STE A
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-8773
Practice Address - Country:US
Practice Address - Phone:616-229-0269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI2901600924122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program