Healthcare Provider Details

I. General information

NPI: 1295335891
Provider Name (Legal Business Name): JANELLE MCQUEEN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2020
Last Update Date: 11/01/2020
Certification Date: 11/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29702 SOUTHFIELD RD STE H
SOUTHFIELD MI
48076-2096
US

IV. Provider business mailing address

3574 WABEEK LAKE DR W
BLOOMFIELD HILLS MI
48302-1271
US

V. Phone/Fax

Practice location:
  • Phone: 248-559-4800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901022805
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: