MEDICARE: RYAN MCCORMICK

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	1223G0001X	General Practice Dentistry	2020008459	MO
2	122300000X	Dentist	2020008459	MO

General Provider Information

NPI Number	:	1558881649
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN MCCORMICK

Provider Business Mailing Address
First Line	:	4527 FOREST PARK AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-2113
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4527 FOREST PARK AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-2113
Country	:	US
Telephone Number	:	314-858-5750
Fax Number	:

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

Provider Enumeration Date	:	06/21/2017
Last Update Date	:	06/25/2020

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Directions to “ RYAN MCCORMICK ” Practice Location

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