Provider Demographics
NPI:1689045718
Name:MCCORMACK DENTAL IMAGING
Entity Type:Organization
Organization Name:MCCORMACK DENTAL IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:N
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:DLXT
Authorized Official - Phone:415-421-1389
Mailing Address - Street 1:450 SUTTER ST
Mailing Address - Street 2:SUITE 1542
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94108-4206
Mailing Address - Country:US
Mailing Address - Phone:415-421-1389
Mailing Address - Fax:
Practice Address - Street 1:1550 HOTEL CIR N
Practice Address - Street 2:STE. 340
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2901
Practice Address - Country:US
Practice Address - Phone:619-296-6132
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHP00053519292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory