Healthcare Provider Details

I. General information

NPI: 1851656375
Provider Name (Legal Business Name): JENELLE LOUISE FLEAGLE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5509 BENDT DR STE 302
RAPID CITY SD
57702-9460
US

IV. Provider business mailing address

5509 BENDT DR STE 302
RAPID CITY SD
57702-9460
US

V. Phone/Fax

Practice location:
  • Phone: 605-939-7992
  • Fax:
Mailing address:
  • Phone: 605-939-7992
  • Fax: 605-534-1599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30-023733
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD1324
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: