Provider Demographics
NPI:1467812297
Name:MICHAEL E MCKENZIE JR, DDS LLC
Entity Type:Organization
Organization Name:MICHAEL E MCKENZIE JR, DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-822-3107
Mailing Address - Street 1:2903 SAINT MARYS AVE
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-3714
Mailing Address - Country:US
Mailing Address - Phone:573-221-0440
Mailing Address - Fax:
Practice Address - Street 1:2903 SAINT MARYS AVE
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-3714
Practice Address - Country:US
Practice Address - Phone:573-822-3107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015017896122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty