Healthcare Provider Details

I. General information

NPI: 1003336215
Provider Name (Legal Business Name): JAMES NATHAN MCKENNA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 04/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 S 12TH AVE
PHOENIX AZ
85007-3101
US

IV. Provider business mailing address

1145 10TH AVE E UNIT 318
SEATTLE WA
98102-4086
US

V. Phone/Fax

Practice location:
  • Phone: 602-362-0744
  • Fax:
Mailing address:
  • Phone: 509-710-8180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD009935
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: