Provider Demographics
NPI:1073513172
Name:MCKENZIE, JAVON A (DDS)
Entity Type:Individual
Prefix:MRS
First Name:JAVON
Middle Name:A
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:154 SE RIO ANGELICA
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984
Mailing Address - Country:US
Mailing Address - Phone:954-995-0041
Mailing Address - Fax:678-247-7862
Practice Address - Street 1:3227 W BLUE RIDGE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-3905
Practice Address - Country:US
Practice Address - Phone:864-295-8888
Practice Address - Fax:864-295-1241
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX-3977Medicaid