Provider Demographics
NPI:1083931380
Name:MCKINNON, MARQUISH
Entity Type:Individual
Prefix:
First Name:MARQUISH
Middle Name:
Last Name:MCKINNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 SAINT GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:TX
Mailing Address - Zip Code:78629-3910
Mailing Address - Country:US
Mailing Address - Phone:830-672-6511
Mailing Address - Fax:830-672-6430
Practice Address - Street 1:228 SAINT GEORGE ST
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:TX
Practice Address - Zip Code:78629-3910
Practice Address - Country:US
Practice Address - Phone:830-672-6511
Practice Address - Fax:830-672-6430
Is Sole Proprietor?:No
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3227126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant