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General NPI Number Information
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NPI Number | 1558895243
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Entity Type | Organization
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Legal Business Name | MC CORMACK DENTAL XRAY INC.
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Dates
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Enumeration Date | 04/19/2017
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Last Update Date | 04/19/2017
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Provider Practice Location Address
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Address Line | 395 N. SECOND AVE.
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City | UPLAND
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State | CA
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Zip | 91786
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Country | US
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Telephone | 909-985-3030
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Fax | 909-946-1200
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Provider Business Mailing Address
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Address Line | 395 N. SECOND AVE.
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City | UPLAND
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State | CA
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Zip | 91786
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Country | US
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Telephone | 909-985-3030
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Fax | 909-946-1200
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Authorized Official
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Title or Position | PRESIDENT/X-RAY TECH
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Name | MRS. VALERIE J WELLS
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Credential | LICENSED CALIFORNIA
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Telephone | 909-921-4273
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2471C3401X
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Taxonomy Name | Computed Tomography Radiologic Technologist
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License Number | RHP00040925
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License Number State | CA
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