Healthcare Provider Details

I. General information

NPI: 1417008103
Provider Name (Legal Business Name): SUEZAN C. MCCORMICK DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 HWY 556
MEADVILLE MS
39653
US

IV. Provider business mailing address

PO BOX 758
MEADVILLE MS
39653-0758
US

V. Phone/Fax

Practice location:
  • Phone: 601-384-5891
  • Fax: 601-384-5878
Mailing address:
  • Phone: 601-384-5891
  • Fax: 601-384-5878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number262691
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: