Healthcare Provider Details

I. General information

NPI: 1023767217
Provider Name (Legal Business Name): MACKENZIE SUE HENRY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LACKAWANNA AVE UNIT 107
SCRANTON PA
18503-2001
US

IV. Provider business mailing address

300 LACKAWANNA AVE UNIT 107
SCRANTON PA
18503-2001
US

V. Phone/Fax

Practice location:
  • Phone: 570-343-4472
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1023767217
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: