Provider Demographics
NPI:1538189469
Name:SUSAN M. MCKINLEY, DDS, PA
Entity type:Organization
Organization Name:SUSAN M. MCKINLEY, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MCKINLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-867-7116
Mailing Address - Street 1:224 S NEW HOPE RD STE I
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4873
Mailing Address - Country:US
Mailing Address - Phone:704-867-7116
Mailing Address - Fax:704-854-9188
Practice Address - Street 1:224 S NEW HOPE RD STE I
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4873
Practice Address - Country:US
Practice Address - Phone:704-867-7116
Practice Address - Fax:704-854-9188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC61141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7995802Medicaid