=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629891957
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MCKENNA MERGES DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2024
-----------------------------------------------------
Last Update Date | 11/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 LARKIN AVE STE 120
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60123-5808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-697-1111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1617 N ARTESIAN AVE APT 2N
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-6058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-991-1295
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0001X
-----------------------------------------------------
Taxonomy Name | Public Health Dentistry
-----------------------------------------------------
License Number | 019035564
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------