Provider Demographics
NPI:1982394631
Name:BOSTIC-FENNELL, JENAI
Entity Type:Individual
Prefix:MRS
First Name:JENAI
Middle Name:
Last Name:BOSTIC-FENNELL
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 1:1919 7TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-2005
Mailing Address - Country:US
Mailing Address - Phone:205-934-3387
Mailing Address - Fax:
Practice Address - Street 1:2635 LEE RD STE C4
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-3356
Practice Address - Country:US
Practice Address - Phone:770-501-3794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN123151122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist