Healthcare Provider Details

I. General information

NPI: 1073561213
Provider Name (Legal Business Name): ADAM JOHN MCKISSOCK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOHN MCKISSOCK DMD

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 05/16/2022
Certification Date: 05/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 JET STREAM DR STE 110
COLORADO SPRINGS CO
80921-3938
US

IV. Provider business mailing address

1720 JET STREAM DR STE 110
COLORADO SPRINGS CO
80921-3938
US

V. Phone/Fax

Practice location:
  • Phone: 719-488-2188
  • Fax: 719-488-2188
Mailing address:
  • Phone: 719-488-2188
  • Fax: 719-488-2188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN 16025
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number9878
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: