Healthcare Provider Details

I. General information

NPI: 1013991660
Provider Name (Legal Business Name): HERBERT MCKINNEY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 06/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4323 HILL ST.
FORT JACKSON SC
29207-5604
US

IV. Provider business mailing address

4323 HILL ST.
FORT JACKSON SC
29207-5604
US

V. Phone/Fax

Practice location:
  • Phone: 803-751-6213
  • Fax: 803-751-6886
Mailing address:
  • Phone: 803-751-6213
  • Fax: 803-751-6886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2505
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: