=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023209574
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL S MCCORMICK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2007
-----------------------------------------------------
Last Update Date | 10/18/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33 CENTER ST
-----------------------------------------------------
City | EAST AURORA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14052-2244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-652-1140
-----------------------------------------------------
Fax | 716-655-4182
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33 CENTER ST
-----------------------------------------------------
City | EAST AURORA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14052-2244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-652-1140
-----------------------------------------------------
Fax | 716-655-4182
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL S MCCORMICK
-----------------------------------------------------
Credential | DMD, LLC
-----------------------------------------------------
Telephone | 716-652-1140
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 047306
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------