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General NPI Number Information
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NPI Number | 1104286996
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Entity Type | Organization
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Legal Business Name | MCCORMACK DENTAL IMAGING
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Dates
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Enumeration Date | 03/07/2016
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Last Update Date | 03/07/2016
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Provider Practice Location Address
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Address Line | 317 N EL CAMINO REAL STE. 301
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City | ENCINITAS
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State | CA
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Zip | 92024-2811
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Country | US
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Telephone | 760-942-2133
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Fax |
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Provider Business Mailing Address
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Address Line | 450 SUTTER ST STE. 1542
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City | SAN FRANCISCO
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State | CA
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Zip | 94108-4206
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Country | US
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Telephone | 415-421-1389
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. JEROME N. PECK
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Credential | DLXT
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Telephone | 415-421-1389
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 292200000X
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Taxonomy Name | Dental Laboratory
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License Number | RHP00053519
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License Number State | CA
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