Provider Demographics
NPI:1316006547
Name:MCCOY, MARK J (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:MCCOY
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 1:529 PRINCE ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-3627
Mailing Address - Country:US
Mailing Address - Phone:843-224-5575
Mailing Address - Fax:
Practice Address - Street 1:201 RONNIE CT
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-4136
Practice Address - Country:US
Practice Address - Phone:843-236-2273
Practice Address - Fax:843-236-7303
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC 3610122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist