Healthcare Provider Details

I. General information

NPI: 1093704272
Provider Name (Legal Business Name): GARY EDWARD MCKENNA D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 08/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 N HIGH ST
MORRISTOWN TN
37814-3863
US

IV. Provider business mailing address

1314 BALES DR
MORRISTOWN TN
37814-6102
US

V. Phone/Fax

Practice location:
  • Phone: 423-581-1611
  • Fax: 423-581-2045
Mailing address:
  • Phone: 423-581-9248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS0000001671
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: