MEDICARE: MARK J MCCOY 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	122300000X	Dentist	SC 3610	SC

General Provider Information

NPI Number	:	1316006547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK J MCCOY DMD

Provider Business Mailing Address
First Line	:	529 PRINCE ST
Second Line	:
City	:	GEORGETOWN
State	:	SC
Zip	:	29440-3627
Country	:	US
Telephone Number	:	843-224-5575
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 RONNIE CT
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-4136
Country	:	US
Telephone Number	:	843-236-2273
Fax Number	:	843-236-7303

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

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	07/08/2007

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