Provider Demographics
NPI:1285831123
Name:MCKINNEY, THERESA LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:LYNN
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9272 W CHARLOTTE DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-7210
Mailing Address - Country:US
Mailing Address - Phone:937-405-9347
Mailing Address - Fax:
Practice Address - Street 1:9272 W CHARLOTTE DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-7210
Practice Address - Country:US
Practice Address - Phone:937-405-9347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30 022571122300000X
IDD-5457122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist