Provider Demographics
NPI:1386101350
Name:MCKENZIE, GILLIAN SHANNON (RDH)
Entity type:Individual
Prefix:
First Name:GILLIAN
Middle Name:SHANNON
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:GILLIAN
Other - Middle Name:SHANNON
Other - Last Name:SEVERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:2592 KWINA RD
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-9278
Mailing Address - Country:US
Mailing Address - Phone:360-312-2489
Mailing Address - Fax:360-384-2336
Practice Address - Street 1:2592 KWINA RD
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-9278
Practice Address - Country:US
Practice Address - Phone:360-312-2489
Practice Address - Fax:360-384-2336
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHL60783437124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAHL60783737OtherWA STATE LICENSE