Provider Demographics
NPI:1720207673
Name:MCKINNEY, IVAN (DDS)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:MCKINNEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3802 BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-9420
Mailing Address - Country:US
Mailing Address - Phone:903-581-0581
Mailing Address - Fax:903-581-3978
Practice Address - Street 1:3802 BROOKSIDE DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-9420
Practice Address - Country:US
Practice Address - Phone:903-581-0581
Practice Address - Fax:903-581-3978
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX585455OtherUNITED CONCORDIA
TXD10724OtherBLUE CROSS BLUE SHIELD
TX$$$$$$$$$OtherSTERLING LIFE INSURANCE
TX$$$$$$$$$OtherUMB
TX$$$$$$$$$OtherWEB TPA
TX$$$$$$$$$OtherHEALTHPAYERS USA
TXD10724OtherBLUE CROSS BLUE SHIELD
TX$$$$$$$$$OtherHUMANA DENTAL
TX$$$$$$$$$OtherASSURANT EMPLOYEE BENEFITS
TX$$$$$$$$$OtherAFLAC
TX$$$$$$$$$OtherGUARDIAN
TX$$$$$$$$$OtherTML IEBP
TX585455OtherUNITED CONCORDIA
TX$$$$$$$$$OtherMETLIFE
TX$$$$$$$$$OtherTRICARE
TX$$$$$$$$$OtherCIGNA DENTAL
TX$$$$$$$$$OtherUNITED HEALTHCARE DENTAL
TX$$$$$$$$$OtherBENEFIT PLANNERS
TX$$$$$$$$$OtherDELTA DENTAL
TX$$$$$$$$$OtherSUN LIFE AND HEALTH
TX$$$$$$$$$OtherDENTAL NETWORK OF AMERICA