Provider Demographics
NPI:1598147795
Name:MCKENZIE, MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MCKENZIE
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 1:2903 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:573-221-0440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20150178961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice