Provider Demographics
NPI:1770192767
Name:COLSON, MACKENZIE (DDS)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:COLSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5611 W 134TH TER APT 1718
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66209-4060
Mailing Address - Country:US
Mailing Address - Phone:316-519-7485
Mailing Address - Fax:
Practice Address - Street 1:5611 W 134TH TER APT 1718
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66209-4060
Practice Address - Country:US
Practice Address - Phone:316-519-7485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200226131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice