Healthcare Provider Details

I. General information

NPI: 1063420040
Provider Name (Legal Business Name): MCCORMICK FAMILY DENTAL CARE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5610 MEDICAL CIRCLE STE 10
MADISON WI
53719
US

IV. Provider business mailing address

5610 MEDICAL CIRCLE STE 10
MADISON WI
53719
US

V. Phone/Fax

Practice location:
  • Phone: 608-233-5351
  • Fax: 608-238-6777
Mailing address:
  • Phone: 608-233-5351
  • Fax: 608-238-6777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3143
License Number StateWI

VIII. Authorized Official

Name: DR. STUART J MCCORMICK
Title or Position: OWNER
Credential: DDS
Phone: 608-233-5351