Provider Demographics
NPI:1225186703
Name:MCKINLEY, OTIS L (DDS)
Entity Type:Individual
Prefix:DR
First Name:OTIS
Middle Name:L
Last Name:MCKINLEY
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 1:312 E SAGINAW ST
Mailing Address - Street 2:
Mailing Address - City:AU GRES
Mailing Address - State:MI
Mailing Address - Zip Code:48703-9637
Mailing Address - Country:US
Mailing Address - Phone:989-876-7141
Mailing Address - Fax:989-876-6680
Practice Address - Street 1:312 E SAGINAW ST
Practice Address - Street 2:
Practice Address - City:AU GRES
Practice Address - State:MI
Practice Address - Zip Code:48703-9637
Practice Address - Country:US
Practice Address - Phone:989-876-7141
Practice Address - Fax:989-876-6680
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI109061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice