Provider Demographics
NPI:1073594214
Name:MCKINNEY, DAN RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:RICHARD
Last Name:MCKINNEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4364
Mailing Address - Country:US
Mailing Address - Phone:505-763-4851
Mailing Address - Fax:505-769-0249
Practice Address - Street 1:116 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4364
Practice Address - Country:US
Practice Address - Phone:505-763-4851
Practice Address - Fax:505-769-0249
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD822122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM008419Medicaid
NM85522OtherDORAL CONSULT EC