Provider Demographics
NPI:1558895243
Name:MC CORMACK DENTAL XRAY INC.
Entity Type:Organization
Organization Name:MC CORMACK DENTAL XRAY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/X-RAY TECH
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED CALIFORNIA
Authorized Official - Phone:909-921-4273
Mailing Address - Street 1:395 N. SECOND AVE.
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786
Mailing Address - Country:US
Mailing Address - Phone:909-985-3030
Mailing Address - Fax:909-946-1200
Practice Address - Street 1:395 N. SECOND AVE.
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786
Practice Address - Country:US
Practice Address - Phone:909-985-3030
Practice Address - Fax:909-946-1200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHP000409252471C3401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed TomographyGroup - Single Specialty