Provider Demographics
NPI:1073561213
Name:MCKISSOCK, ADAM JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:JOHN
Last Name:MCKISSOCK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:MCKISSOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1720 JET STREAM DR STE 110
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-3938
Mailing Address - Country:US
Mailing Address - Phone:719-488-2188
Mailing Address - Fax:719-488-2188
Practice Address - Street 1:1720 JET STREAM DR STE 110
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921-3938
Practice Address - Country:US
Practice Address - Phone:719-488-2188
Practice Address - Fax:719-488-2188
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 160251223E0200X, 1223E0200X
CO98781223E0200X
CODEN.000098781223E0200X
CODEN-98781223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodontics