Provider Demographics
NPI:1639236185
Name:T M MCKENNA INC
Entity Type:Organization
Organization Name:T M MCKENNA INC
Other - Org Name:T M MCKENNA DDS PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:636-394-5215
Mailing Address - Street 1:453 LAFAYETTE CENTER
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MO
Mailing Address - Zip Code:63011-3943
Mailing Address - Country:US
Mailing Address - Phone:636-394-5215
Mailing Address - Fax:
Practice Address - Street 1:453 LAFAYETTE CENTER
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:MO
Practice Address - Zip Code:63011-3943
Practice Address - Country:US
Practice Address - Phone:636-394-5215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO12263122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty