=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356562599
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM THOMAS MCKENZIE JR. DMD, MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3443 TAMIAMI TRL SUITE D
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33952-8159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-629-3443
-----------------------------------------------------
Fax | 941-629-7616
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3443 TAMIAMI TRL SUITE D
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33952-8159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-629-3443
-----------------------------------------------------
Fax | 941-629-7616
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | DN11486
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------