MEDICARE: DR. ADAM JOHN MCKISSOCK DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	DN 16025	FL
2	1223E0200X	Endodontics	9878	CO

General Provider Information

NPI Number	:	1073561213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ADAM JOHN MCKISSOCK DMD

Provider Business Mailing Address
First Line	:	1720 JET STREAM DR STE 110
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-3938
Country	:	US
Telephone Number	:	719-488-2188
Fax Number	:	719-488-2188

Provider Business Practice Location Address
First Line	:	1720 JET STREAM DR STE 110
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-3938
Country	:	US
Telephone Number	:	719-488-2188
Fax Number	:	719-488-2188

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	05/16/2022

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