Basic Information
Provider Information | |||||||||
NPI: | 1962409946 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCKANE | ||||||||
FirstName: | STEVEN | ||||||||
MiddleName: | RAYMOND | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | US ARMY DENTAL HEALTH ACTIVITY | ||||||||
Address2: | 4301 WILSON STREET, OFFICE GD152 | ||||||||
City: | FORT SILL | ||||||||
State: | OK | ||||||||
PostalCode: | 73503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5804425925 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | US ARMY DENTAL HEALTH ACTIVITY | ||||||||
Address2: | 4301 WILSON STREET, OFFICE GD152 | ||||||||
City: | FORT SILL | ||||||||
State: | OK | ||||||||
PostalCode: | 73503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5804425925 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2005 | ||||||||
LastUpdateDate: | 02/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 03/20/2006 | ||||||||
NPIReactivationDate: | 03/27/2006 | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/31/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 9724 | MD | Y |   | Dental Providers | Dentist | General Practice |
No ID Information.