Provider Demographics
NPI:1598515454
Name:MCCORMICK, KRISTEN MARIE (RDH)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:MARIE
Other - Last Name:PRUSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1044 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12307-1508
Mailing Address - Country:US
Mailing Address - Phone:518-370-1441
Mailing Address - Fax:518-395-9431
Practice Address - Street 1:1108 STATE ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12304-2610
Practice Address - Country:US
Practice Address - Phone:518-370-1441
Practice Address - Fax:518-395-9431
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026240124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist