Provider Demographics
NPI:1598237307
Name:FENA, KELLI MARIE (DH)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:MARIE
Last Name:FENA
Suffix:
Gender:F
Credentials:DH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5219 SAINT JOHN DR
Mailing Address - Street 2:
Mailing Address - City:ORR
Mailing Address - State:MN
Mailing Address - Zip Code:55771-8232
Mailing Address - Country:US
Mailing Address - Phone:218-757-3650
Mailing Address - Fax:
Practice Address - Street 1:1613 FARM RD S
Practice Address - Street 2:
Practice Address - City:TOWER
Practice Address - State:MN
Practice Address - Zip Code:55790-5579
Practice Address - Country:US
Practice Address - Phone:218-753-2182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist