MEDICARE: MRS. JAVON A. MCKENZIE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	3977	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073513172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JAVON A. MCKENZIE DDS

Provider Business Mailing Address
First Line	:	154 SE RIO ANGELICA
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34984
Country	:	US
Telephone Number	:	954-995-0041
Fax Number	:	678-247-7862

Provider Business Practice Location Address
First Line	:	3227 W BLUE RIDGE DR
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29611-3905
Country	:	US
Telephone Number	:	864-295-8888
Fax Number	:	864-295-1241

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	08/07/2018

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