Basic Information
Provider Information | |||||||||
NPI: | 1932427317 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCKENZIE | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | STUART | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 324 22ND AVE N | ||||||||
Address2: |   | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372031842 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153294401 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 324 22ND AVE N | ||||||||
Address2: |   | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372031842 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153294401 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2010 | ||||||||
LastUpdateDate: | 07/05/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 5850 C1 | AL | N |   | Dental Providers | Dentist |   | 1223S0112X | 10028 | TN | N |   | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 204E00000X | 53940 | TN | Y |   | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |   | 204E00000X | 10028 | TN | N |   | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |   |
ID Information
ID | Type | State | Issuer | Description | Q022069 | 05 | TN |   | MEDICAID |