Provider Demographics
NPI:1669551248
Name:MCKENZIE, SCOTT C (DMD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:C
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 HAMILTON MILL RD
Mailing Address - Street 2:SUITE106
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-4080
Mailing Address - Country:US
Mailing Address - Phone:678-714-7541
Mailing Address - Fax:678-714-7543
Practice Address - Street 1:3300 HAMILTON MILL RD
Practice Address - Street 2:SUITE106
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-4080
Practice Address - Country:US
Practice Address - Phone:678-714-7541
Practice Address - Fax:678-714-7543
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0127861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADN012786Medicaid