Healthcare Provider Details

I. General information

NPI: 1710954623
Provider Name (Legal Business Name): KENNETH J. MCCORMICK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 S PARKER ST
MARINE CITY MI
48039-3585
US

IV. Provider business mailing address

540 S PARKER ST
MARINE CITY MI
48039-3585
US

V. Phone/Fax

Practice location:
  • Phone: 810-765-1440
  • Fax: 810-765-3752
Mailing address:
  • Phone: 810-765-1440
  • Fax: 810-765-3752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12658
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: