Healthcare Provider Details

I. General information

NPI: 1962416875
Provider Name (Legal Business Name): KEVIN MCCOY, DDS, MS, P. C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 17TH ST
JACKSON MI
49203-1409
US

IV. Provider business mailing address

719 17TH ST
JACKSON MI
49203-1409
US

V. Phone/Fax

Practice location:
  • Phone: 517-782-2439
  • Fax:
Mailing address:
  • Phone: 517-782-2439
  • 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: KEVIN MARTIN MCCOY
Title or Position: OWNER
Credential:
Phone: 517-782-2439