Healthcare Provider Details

I. General information

NPI: 1215092820
Provider Name (Legal Business Name): PATRICK MICHAEL MCCORMICK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E STATE ST
MAUSTON WI
53948
US

IV. Provider business mailing address

510 E STATE ST
MAUSTON WI
53948
US

V. Phone/Fax

Practice location:
  • Phone: 608-847-5614
  • Fax: 608-847-7265
Mailing address:
  • Phone: 608-847-5614
  • Fax: 608-847-7265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5001326WI
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: