Provider Demographics
NPI:1518280072
Name:BRAD A. MCKENZIE
Entity Type:Organization
Organization Name:BRAD A. MCKENZIE
Other - Org Name:MCKENZIE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-622-3085
Mailing Address - Street 1:PO BOX 293
Mailing Address - Street 2:
Mailing Address - City:WELCHES
Mailing Address - State:OR
Mailing Address - Zip Code:97067-0293
Mailing Address - Country:US
Mailing Address - Phone:503-622-3085
Mailing Address - Fax:503-622-3753
Practice Address - Street 1:24540 E WELCHES RD
Practice Address - Street 2:
Practice Address - City:WELCHES
Practice Address - State:OR
Practice Address - Zip Code:97067
Practice Address - Country:US
Practice Address - Phone:503-622-3085
Practice Address - Fax:503-622-3753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7819122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1285634097OtherINDIVIDUAL NPI