Provider Demographics
NPI:1114054996
Name:MCKERLIE, VICTOR R (DMD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:R
Last Name:MCKERLIE
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 1:27562 BIG BEND RD
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-3937
Mailing Address - Country:US
Mailing Address - Phone:928-273-4054
Mailing Address - Fax:
Practice Address - Street 1:5302 E VAN BUREN ST
Practice Address - Street 2:# 3039
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-7965
Practice Address - Country:US
Practice Address - Phone:928-273-4054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ44191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice