Provider Demographics
NPI:1114920196
Name:MCKENNA, MARK JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOSEPH
Last Name:MCKENNA
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 1:424 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-3863
Mailing Address - Country:US
Mailing Address - Phone:423-581-2000
Mailing Address - Fax:423-581-2045
Practice Address - Street 1:424 N HIGH ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3863
Practice Address - Country:US
Practice Address - Phone:423-581-2000
Practice Address - Fax:423-581-2045
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN077331223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics