Provider Demographics
NPI:1518007723
Name:SELF, MCKINLEY T (DMD)
Entity Type:Individual
Prefix:DR
First Name:MCKINLEY
Middle Name:T
Last Name:SELF
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9902 NE MONSAAS RD
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-1103
Mailing Address - Country:US
Mailing Address - Phone:360-464-0779
Mailing Address - Fax:
Practice Address - Street 1:9902 NE MONSAAS RD
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-1103
Practice Address - Country:US
Practice Address - Phone:360-464-0779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010260122300000X
NV5091122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist