Provider Demographics
NPI:1386425338
Name:FUTRELL, ALEXIS N
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:N
Last Name:FUTRELL
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 1:3554 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-5263
Mailing Address - Country:US
Mailing Address - Phone:517-745-7709
Mailing Address - Fax:
Practice Address - Street 1:122 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-9164
Practice Address - Country:US
Practice Address - Phone:517-740-7422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902018569124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist