Ivan McKinney, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

10724 Issued in TX

Practice address

3802 Brookside Dr
Tyler, TX 75701-9420

Phone

(903) 581-0581

Fax

(903) 581-3978

NPI assigned

Apr 25, 2007

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in TX

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1177459200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1213228800000",
    "number": "1720207673",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3802 BROOKSIDE DR",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757019420",
            "telephone_number": "903-581-0581",
            "fax_number": "903-581-3978"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3802 BROOKSIDE DR",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757019420",
            "telephone_number": "903-581-0581",
            "fax_number": "903-581-3978"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MCKINNEY",
        "first_name": "IVAN",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-04-25",
        "last_updated": "2008-06-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "TX",
            "license": "10724",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED CONCORDIA",
            "identifier": "585455",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "D10724",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Michael McKelva
• Jennifer May McKenzie, RN
• Robert Wayne McKenzie, PH.D.
• Deborah McKinley- Waggoner
• James Wayne McKinley, M.D.
• John Ronald McKinney Jr., DO
• Melissa McKinney
• Robert A McKinney Jr., MD
• Shoncy McKinney
• Lonny R McKinzie, DC

• General Practice Dentistry in Tyler, TX
• Providers in Tyler, TX by specialty
• General Practice Dentistry in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 12, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.