MEDICARE: MICHAEL E MCKENZIE JR, DDS LLC

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	122300000X	Dentist	2015017896	MO

General Provider Information

NPI Number	:	1467812297
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL E MCKENZIE JR, DDS LLC

Provider Business Mailing Address
First Line	:	2903 SAINT MARYS AVE
Second Line	:
City	:	HANNIBAL
State	:	MO
Zip	:	63401-3714
Country	:	US
Telephone Number	:	573-221-0440
Fax Number	:

Provider Business Practice Location Address
First Line	:	2903 SAINT MARYS AVE
Second Line	:
City	:	HANNIBAL
State	:	MO
Zip	:	63401-3714
Country	:	US
Telephone Number	:	573-822-3107
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. MICHAEL E MCKENZIE JR.
Credential	:	DDS
Telephone Number	:	573-822-3107

Provider Enumeration Date	:	03/07/2016
Last Update Date	:	03/07/2016

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