Provider Demographics
NPI:1710170733
Name:BRENT C. MACKAY D.D.S., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:BRENT C. MACKAY D.D.S., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:CALVIN
Authorized Official - Last Name:MACKAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:530-877-8694
Mailing Address - Street 1:5571 SCOTTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:PARADISE
Mailing Address - State:CA
Mailing Address - Zip Code:95969-5043
Mailing Address - Country:US
Mailing Address - Phone:530-877-8694
Mailing Address - Fax:530-877-8038
Practice Address - Street 1:5571 SCOTTWOOD RD
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-5043
Practice Address - Country:US
Practice Address - Phone:530-877-8694
Practice Address - Fax:530-877-8038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA255881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB25588-01OtherMEDI-CAL DENTAL PROGRAM