=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558465971
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELIA YVETTE KENNEBREW HORTON DDS,MS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2006
-----------------------------------------------------
Last Update Date | 10/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29556 SOUTHFIELD RD SUITE 100
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-552-1195
-----------------------------------------------------
Fax | 248-552-0980
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29556 SOUTHFIELD RD SUITE 100
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-552-1195
-----------------------------------------------------
Fax | 248-552-0980
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 2901015296
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------