Provider Demographics
NPI:1003460858
Name:PICKAR, DANIEL MACKENZIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:MACKENZIE
Last Name:PICKAR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 BUDLONG RD
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-6429
Mailing Address - Country:US
Mailing Address - Phone:401-944-8100
Mailing Address - Fax:
Practice Address - Street 1:115 BUDLONG RD
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6429
Practice Address - Country:US
Practice Address - Phone:401-944-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
RIDEN034801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program