Provider Demographics
NPI:1225188642
Name:MCKINNEY, JON M (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:M
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 1:701 N RIVER ST
Mailing Address - Street 2:
Mailing Address - City:SPOONER
Mailing Address - State:WI
Mailing Address - Zip Code:54801-1311
Mailing Address - Country:US
Mailing Address - Phone:715-635-8282
Mailing Address - Fax:715-635-3994
Practice Address - Street 1:701 N RIVER ST
Practice Address - Street 2:
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801-1311
Practice Address - Country:US
Practice Address - Phone:715-635-8282
Practice Address - Fax:715-635-3994
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5000443122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI769116OtherUNITED CONCORDIA
WI33667700Medicaid