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General NPI Number Information
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NPI Number | 1730507062
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Entity Type | Organization
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Legal Business Name | BOONE FAMILY DENTISTRY
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Dates
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Enumeration Date | 04/03/2014
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Last Update Date | 10/16/2019
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Provider Practice Location Address
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Address Line | 1805 S. LINN ST
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City | BOONE
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State | IA
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Zip | 50036-5312
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Country | US
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Telephone | 515-432-6244
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Fax | 515-432-2975
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Provider Business Mailing Address
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Address Line | 1805 S. LINN ST
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City | BOONE
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State | IA
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Zip | 50036-5312
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Country | US
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Telephone | 515-432-6244
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Fax | 515-432-2975
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Authorized Official
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Title or Position | DENTIST
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Name | DR. MARK C MCKENNY
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Credential | DDS
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Telephone | 515-432-6244
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 08700
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License Number State | IA
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