Provider Demographics
NPI:1558846824
Name:SORENSEN, MCKENZIE DAILE (DDS)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:DAILE
Last Name:SORENSEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4438 39TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-4608
Mailing Address - Country:US
Mailing Address - Phone:619-519-4455
Mailing Address - Fax:
Practice Address - Street 1:145 S LAS POSAS RD STE 162
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078
Practice Address - Country:US
Practice Address - Phone:760-736-4247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1036621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice