Provider Demographics
NPI:1376712075
Name:JOHNNY L. MCKINNON, JR., D.D.S., P.A.
Entity Type:Organization
Organization Name:JOHNNY L. MCKINNON, JR., D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCKINNON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-439-9744
Mailing Address - Street 1:PO BOX 22
Mailing Address - Street 2:407 NORTH MAIN STREET
Mailing Address - City:MOUNT GILEAD
Mailing Address - State:NC
Mailing Address - Zip Code:27306-0022
Mailing Address - Country:US
Mailing Address - Phone:910-439-9744
Mailing Address - Fax:910-439-4113
Practice Address - Street 1:407 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:MT. GILEAD
Practice Address - State:NC
Practice Address - Zip Code:27306-0022
Practice Address - Country:US
Practice Address - Phone:910-439-9744
Practice Address - Fax:910-439-4113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC60631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8995803Medicaid