Provider Demographics
NPI:1679595805
Name:MCKINZIE, SCOTT ANDREW (DMD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:ANDREW
Last Name:MCKINZIE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3931 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-1005
Mailing Address - Country:US
Mailing Address - Phone:510-654-3030
Mailing Address - Fax:
Practice Address - Street 1:3931 GRAND AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-1005
Practice Address - Country:US
Practice Address - Phone:510-654-3030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA540951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice