Provider Demographics
NPI:1972611507
Name:FENN, ANITA (DMD)
Entity type:Individual
Prefix:DR
First Name:ANITA
Middle Name:
Last Name:FENN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 N MIDWAY ST
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:AL
Mailing Address - Zip Code:36016-3119
Mailing Address - Country:US
Mailing Address - Phone:334-775-8951
Mailing Address - Fax:
Practice Address - Street 1:175 N MIDWAY ST
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:AL
Practice Address - Zip Code:36016-3119
Practice Address - Country:US
Practice Address - Phone:334-775-8951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4632122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DNT00Medicare UPIN