Healthcare Provider Details

I. General information

NPI: 1891007225
Provider Name (Legal Business Name): MICHAEL SHAWN MCCORMACK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2573 STATE HIGHWAY 522
QUESTA NM
87556-0290
US

IV. Provider business mailing address

2573 STATE HIGHWAY 522
QUESTA NM
87556-0290
US

V. Phone/Fax

Practice location:
  • Phone: 575-586-0315
  • Fax: 505-443-8353
Mailing address:
  • Phone: 575-586-0315
  • Fax: 505-443-8353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDB-2026-0084
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number00201972
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDE61574138
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: