Provider Demographics
NPI:1124502620
Name:RAY, MCKENZIE ROSE
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:ROSE
Last Name:RAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 617
Mailing Address - Street 2:
Mailing Address - City:SOMERTON
Mailing Address - State:AZ
Mailing Address - Zip Code:85350-0617
Mailing Address - Country:US
Mailing Address - Phone:928-236-8001
Mailing Address - Fax:928-722-6113
Practice Address - Street 1:950 E MAIN ST BLDG B
Practice Address - Street 2:
Practice Address - City:SOMERTON
Practice Address - State:AZ
Practice Address - Zip Code:85350-7409
Practice Address - Country:US
Practice Address - Phone:928-236-8001
Practice Address - Fax:928-722-6113
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH009160124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist