=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114920196
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK JOSEPH MCKENNA D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2005
-----------------------------------------------------
Last Update Date | 01/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 424 N HIGH ST
-----------------------------------------------------
City | MORRISTOWN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37814-3863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-581-2000
-----------------------------------------------------
Fax | 423-581-2045
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 424 N HIGH ST
-----------------------------------------------------
City | MORRISTOWN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37814-3863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-581-2000
-----------------------------------------------------
Fax | 423-581-2045
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 07733
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------