Provider Demographics
NPI:1609089937
Name:MCKINNEYDENTIST.COM
Entity Type:Organization
Organization Name:MCKINNEYDENTIST.COM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-547-6453
Mailing Address - Street 1:1716 W VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75069-7864
Mailing Address - Country:US
Mailing Address - Phone:972-547-6453
Mailing Address - Fax:
Practice Address - Street 1:1716 W VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75069-7864
Practice Address - Country:US
Practice Address - Phone:972-547-6453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201351223G0001X
TX207481223G0001X
TX160341223G0001X
TX157721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty