Basic Information
| Provider Information | |||||||||
| NPI: | 1073513172 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKENZIE | ||||||||
| FirstName: | JAVON | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 154 SE RIO ANGELICA | ||||||||
| Address2: | |||||||||
| City: | PORT SAINT LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549950041 | ||||||||
| FaxNumber: | 6782477862 | ||||||||
| Practice Location | |||||||||
| Address1: | 3227 W BLUE RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296113905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642958888 | ||||||||
| FaxNumber: | 8642951241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 08/07/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 3977 | SC | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | ZX-3977 | 05 | SC | MEDICAID |