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General NPI Number Information
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NPI Number | 1477938140
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Entity Type | Organization
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Legal Business Name | MCKISSOCK CORP.
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Dates
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Enumeration Date | 07/23/2015
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Last Update Date | 08/11/2015
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Provider Practice Location Address
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Address Line | 4769 THE GROVE DR SUITE 100
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City | WINDERMERE
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State | FL
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Zip | 34786-8421
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Country | US
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Telephone | 407-909-1099
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Fax |
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Provider Business Mailing Address
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Address Line | 4769 THE GROVE DR SUITE 100
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City | WINDERMERE
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State | FL
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Zip | 34786-8421
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Country | US
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Telephone | 407-909-1099
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Fax |
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | DR. MATTHEW DEAN MCKISSOCK
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Credential | D.M.D.
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Telephone | 407-909-1099
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN14895
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License Number State | FL
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