Provider Demographics
NPI:1386191641
Name:MCCOURT, DANIELLE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:MCCOURT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3104 HUGO ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-2218
Mailing Address - Country:US
Mailing Address - Phone:623-293-1529
Mailing Address - Fax:
Practice Address - Street 1:6175 EL CAJON BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-3915
Practice Address - Country:US
Practice Address - Phone:619-583-4030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-04
Last Update Date:2016-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100812122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist