Provider Demographics
NPI:1831774082
Name:FERINGA, MACKENZIE ANN
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ANN
Last Name:FERINGA
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 1:1955 S 1300 E STE L2
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-3675
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1955 S 1300 E STE L2
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-3675
Practice Address - Country:US
Practice Address - Phone:385-479-9636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTFF14904021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice