Provider Demographics
NPI:1861588980
Name:MACKENZIE, MICHAEL WILLIAM (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:MACKENZIE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13592 RIVER RD
Mailing Address - Street 2:SUITE #1
Mailing Address - City:DESTREHAN
Mailing Address - State:LA
Mailing Address - Zip Code:70047-5073
Mailing Address - Country:US
Mailing Address - Phone:985-764-2351
Mailing Address - Fax:985-764-7510
Practice Address - Street 1:13592 RIVER RD
Practice Address - Street 2:SUITE #1
Practice Address - City:DESTREHAN
Practice Address - State:LA
Practice Address - Zip Code:70047-5073
Practice Address - Country:US
Practice Address - Phone:985-764-2351
Practice Address - Fax:985-764-7510
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA30881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice