Provider Demographics
NPI:1619385556
Name:MCKENZIE, PHILIP EVAN (DDS, MS, FRCDC)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:EVAN
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:DDS, MS, FRCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 COUNTY ROAD C W STE 2210
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2551
Mailing Address - Country:US
Mailing Address - Phone:763-233-3322
Mailing Address - Fax:
Practice Address - Street 1:3360 NORTHDALE BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-1601
Practice Address - Country:US
Practice Address - Phone:763-233-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND135971223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics