Healthcare Provider Details

I. General information

NPI: 1033320031
Provider Name (Legal Business Name): KEVIN MARTIN MCCOY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 17TH ST
JACKSON MI
49203-1409
US

IV. Provider business mailing address

1846 W HENDERSON ST
CHICAGO IL
60657-2015
US

V. Phone/Fax

Practice location:
  • Phone: 517-782-2439
  • Fax:
Mailing address:
  • Phone: 773-286-5935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901017848
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: