Provider Demographics
NPI:1235689720
Name:MCKINNEY, SHAROD
Entity Type:Individual
Prefix:
First Name:SHAROD
Middle Name:
Last Name:MCKINNEY
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 1:9315 SPENCER HIGHWAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:DEER PARK
Mailing Address - State:TX
Mailing Address - Zip Code:77536
Mailing Address - Country:US
Mailing Address - Phone:201-803-2076
Mailing Address - Fax:
Practice Address - Street 1:1403 DUNN AVE STE 10
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4870
Practice Address - Country:US
Practice Address - Phone:201-803-2076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32709122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist