Provider Demographics
NPI:1609455039
Name:VERBOUT, MCKENZIE KYLE (DDS)
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:KYLE
Last Name:VERBOUT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MCKENZIE
Other - Middle Name:KYLE
Other - Last Name:TIMMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10783 SPRING DR NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-2009
Mailing Address - Country:US
Mailing Address - Phone:218-308-3833
Mailing Address - Fax:
Practice Address - Street 1:2219 PAUL BUNYAN DR NW STE 6-7
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-6188
Practice Address - Country:US
Practice Address - Phone:218-751-2659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MND145751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program