Provider Demographics
NPI:1447663190
Name:MCKIE, PATRICIA
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:
Last Name:MCKIE
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 1:3204 LANCER ST STE A
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-4491
Mailing Address - Country:US
Mailing Address - Phone:219-762-5506
Mailing Address - Fax:
Practice Address - Street 1:3204 LANCER ST STE A
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-4491
Practice Address - Country:US
Practice Address - Phone:219-762-5506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN227771223G0001X
HIDT-2608122300000X
IN12012143A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice