Provider Demographics
NPI:1154723740
Name:FENTON, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FENTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 S ROCHESTER RD
Mailing Address - Street 2:102
Mailing Address - City:CLAWSON
Mailing Address - State:MI
Mailing Address - Zip Code:48017-2149
Mailing Address - Country:US
Mailing Address - Phone:313-434-0402
Mailing Address - Fax:
Practice Address - Street 1:220 S ROCHESTER RD
Practice Address - Street 2:102
Practice Address - City:CLAWSON
Practice Address - State:MI
Practice Address - Zip Code:48017-2149
Practice Address - Country:US
Practice Address - Phone:313-434-0402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other