Provider Demographics
NPI:1669100871
Name:ANDERSON, MCKENZY LYN
Entity type:Individual
Prefix:
First Name:MCKENZY
Middle Name:LYN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 HIGHWAY ST
Mailing Address - Street 2:
Mailing Address - City:POUNDING MILL
Mailing Address - State:VA
Mailing Address - Zip Code:24637-4111
Mailing Address - Country:US
Mailing Address - Phone:276-498-8060
Mailing Address - Fax:
Practice Address - Street 1:3402 KENNEL GAP RD
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:VA
Practice Address - Zip Code:24631
Practice Address - Country:US
Practice Address - Phone:276-498-8069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402207523124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist