MEDICARE: DR. KENNETH J. MCCORMICK D.D.S.

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	12658	MI

General Provider Information

NPI Number	:	1710954623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH J. MCCORMICK D.D.S.

Provider Business Mailing Address
First Line	:	540 S PARKER ST
Second Line	:
City	:	MARINE CITY
State	:	MI
Zip	:	48039-3585
Country	:	US
Telephone Number	:	810-765-1440
Fax Number	:	810-765-3752

Provider Business Practice Location Address
First Line	:	540 S PARKER ST
Second Line	:
City	:	MARINE CITY
State	:	MI
Zip	:	48039-3585
Country	:	US
Telephone Number	:	810-765-1440
Fax Number	:	810-765-3752

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

Provider Enumeration Date	:	03/01/2006
Last Update Date	:	07/08/2007

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