Healthcare Provider Details

I. General information

NPI: 1467462788
Provider Name (Legal Business Name): JEANINE MARIE FELL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 01/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 SOUTH VANBUREN
NEWTON IL
62448
US

IV. Provider business mailing address

605 SOUTH VANBUREN
NEWTON IL
62448
US

V. Phone/Fax

Practice location:
  • Phone: 618-783-3714
  • Fax: 618-783-3294
Mailing address:
  • Phone: 618-783-3714
  • Fax: 618-783-3294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019020343
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: