Provider Demographics
NPI:1659617108
Name:MCKENZIE DENTAL LABORATORY, INC
Entity Type:Organization
Organization Name:MCKENZIE DENTAL LABORATORY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:CDT
Authorized Official - Phone:207-941-8998
Mailing Address - Street 1:PO BOX 8056
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-8056
Mailing Address - Country:US
Mailing Address - Phone:207-941-8998
Mailing Address - Fax:207-941-0222
Practice Address - Street 1:1407 B BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-2496
Practice Address - Country:US
Practice Address - Phone:207-941-8998
Practice Address - Fax:207-941-0222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-02
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes126900000XDental ProvidersDental Laboratory TechnicianGroup - Single Specialty