Provider Demographics
NPI:1134396567
Name:MCNEILL, JOHN J (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:MCNEILL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2401 E 30TH ST BLDG 2
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8986
Mailing Address - Country:US
Mailing Address - Phone:505-326-2611
Mailing Address - Fax:505-326-5152
Practice Address - Street 1:2401 E 30TH ST BLDG 2
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8986
Practice Address - Country:US
Practice Address - Phone:505-326-2611
Practice Address - Fax:505-326-5152
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM11231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMT40816Medicare UPIN
NM2203465Medicare PIN