Provider Demographics
NPI:1508995879
Name:MCCORMICK, JOHNATHON BEAUX SR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHNATHON
Middle Name:BEAUX
Last Name:MCCORMICK
Suffix:SR
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 1:3506 WASHINGTON AVE STE I
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3102
Mailing Address - Country:US
Mailing Address - Phone:228-868-1942
Mailing Address - Fax:228-868-1944
Practice Address - Street 1:3506 WASHINGTON AVE STE I
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3102
Practice Address - Country:US
Practice Address - Phone:228-868-1942
Practice Address - Fax:228-868-1944
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3134-00122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist