Provider Demographics
NPI:1558626929
Name:CRAIK, MACKENZIE (DDS)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:CRAIK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1243 AUGUSTA WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-1807
Mailing Address - Country:US
Mailing Address - Phone:706-855-8989
Mailing Address - Fax:
Practice Address - Street 1:1243 AUGUSTA WEST PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1807
Practice Address - Country:US
Practice Address - Phone:706-855-8989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE604591141223P0221X
ORD100301223P0221X
GADN0159811223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
RILD00078OtherLICENSE NUMBER