=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245496512
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK CHRISTOPHER MCKENNY DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2008
-----------------------------------------------------
Last Update Date | 04/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 S MARSHALL ST
-----------------------------------------------------
City | BOONE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50036-5312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-432-6244
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 S MARSHALL ST
-----------------------------------------------------
City | BOONE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50036-5312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 6754
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 08700
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------