Provider Demographics
NPI:1962898320
Name:FENNELL, ANDREW
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:FENNELL
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 1:20 LIBERTY DR
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:CT
Mailing Address - Zip Code:06248-1552
Mailing Address - Country:US
Mailing Address - Phone:860-228-7878
Mailing Address - Fax:
Practice Address - Street 1:20 LIBERTY DR
Practice Address - Street 2:
Practice Address - City:HEBRON
Practice Address - State:CT
Practice Address - Zip Code:06248
Practice Address - Country:US
Practice Address - Phone:860-228-7878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11608122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice