Provider Demographics
NPI:1942740618
Name:COMMUNITY DENTAL FOR KIDS
Entity Type:Organization
Organization Name:COMMUNITY DENTAL FOR KIDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-734-4712
Mailing Address - Street 1:2131 E LELAND CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-2240
Mailing Address - Country:US
Mailing Address - Phone:480-734-4712
Mailing Address - Fax:
Practice Address - Street 1:1108 W DICKINSON BLVD STE B
Practice Address - Street 2:
Practice Address - City:FORT STOCKTON
Practice Address - State:TX
Practice Address - Zip Code:79735-4201
Practice Address - Country:US
Practice Address - Phone:480-734-4712
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX276381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty