=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740645936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KD MACKIE DDS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2015
-----------------------------------------------------
Last Update Date | 12/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1677 RIVER RD 103
-----------------------------------------------------
City | BOERNE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78006-2446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-331-7355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1677 RIVER RD 103
-----------------------------------------------------
City | BOERNE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78006-2446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-331-7355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KURT DOUGLAS MACKIE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 830-331-7355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 14092
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------