Healthcare Provider Details

I. General information

NPI: 1922199306
Provider Name (Legal Business Name): KENNETH DALE MACKNET JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 POTOMAC PL STE 402
SMYRNA TN
37167-5657
US

IV. Provider business mailing address

625 BAKERS BRIDGE AVE STE 105-226
FRANKLIN TN
37067-1613
US

V. Phone/Fax

Practice location:
  • Phone: 615-462-7682
  • Fax: 615-462-7684
Mailing address:
  • Phone: 615-462-7682
  • Fax: 615-462-7684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA63594
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberA63594
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA63594
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA63594
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: