MEDICARE: MICHAEL 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	2015017896	MO

General Provider Information

NPI Number	:	1598147795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL MCKENZIE DDS

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	:	573-221-0440
Fax Number	:

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

Provider Enumeration Date	:	06/24/2015
Last Update Date	:	02/18/2016

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