Provider Demographics
NPI:1306860028
Name:MCCORMICK, ERIC CLEO (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:CLEO
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 928
Mailing Address - Street 2:
Mailing Address - City:BAY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39422-0928
Mailing Address - Country:US
Mailing Address - Phone:601-764-4173
Mailing Address - Fax:601-764-4975
Practice Address - Street 1:15 WEST EIGHTH AVENUE
Practice Address - Street 2:
Practice Address - City:BAY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39422-0000
Practice Address - Country:US
Practice Address - Phone:601-764-4173
Practice Address - Fax:601-764-4975
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2189-851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
764274OtherUNITED CONCORDIA PROV #
MS00060212Medicaid