Basic Information
| Provider Information | |||||||||
| NPI: | 1922414168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKENZIE | ||||||||
| FirstName: | CASSANDRA | ||||||||
| MiddleName: | COLLINS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, DDS, MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13316 METCALF AVE | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662132804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138515110 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13316 METCALF AVE | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662132804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138515110 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2014 | ||||||||
| LastUpdateDate: | 09/13/2019 | ||||||||
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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 | 1223P0300X | 2014021685 | MO | N | Dental Providers | Dentist | Periodontics | 1223P0300X | 61312 | KS | Y | Dental Providers | Dentist | Periodontics |
ID Information
| ID | Type | State | Issuer | Description | FM4751877 | 01 | MO | DEA | OTHER | 61312 | 01 | KS | PERIODONTICS - KANSAS DENTAL BOARD | OTHER | FM7146106 | 01 | KS | DEA | OTHER | 2014021685 | 01 | MO | DENTAL SPECIALIST - MISSOURI DENTAL BOARD | OTHER |