Provider Demographics
NPI:1205054541
Name:JENNINGS, MICHELLE P (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:P
Last Name:JENNINGS
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 1:325 ST CHARLES CT
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-3676
Mailing Address - Country:US
Mailing Address - Phone:815-838-5042
Mailing Address - Fax:
Practice Address - Street 1:6520 JOLIET RD
Practice Address - Street 2:
Practice Address - City:COUNTRYSIDE
Practice Address - State:IL
Practice Address - Zip Code:60525
Practice Address - Country:US
Practice Address - Phone:708-354-4545
Practice Address - Fax:708-354-0336
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2018-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210015611223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics