Provider Demographics
NPI:1619019817
Name:MACKUS, LYNDA M (DDS)
Entity Type:Individual
Prefix:DR
First Name:LYNDA
Middle Name:M
Last Name:MACKUS
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 1:3168 PORT SHELDON ST
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-9317
Mailing Address - Country:US
Mailing Address - Phone:616-669-2040
Mailing Address - Fax:616-669-3147
Practice Address - Street 1:3168 PORT SHELDON ST
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-9317
Practice Address - Country:US
Practice Address - Phone:616-669-2040
Practice Address - Fax:616-669-3147
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0121721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice