Provider Demographics
NPI:1699806117
Name:MCCORMICK, ANDREW T (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:T
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 FOUNTAIN GROVE PKWY
Mailing Address - Street 2:STE. 200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-5736
Mailing Address - Country:US
Mailing Address - Phone:707-579-9993
Mailing Address - Fax:707-566-0912
Practice Address - Street 1:855 FOUNTAIN GROVE PKWY
Practice Address - Street 2:STE. 200
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-5736
Practice Address - Country:US
Practice Address - Phone:707-579-9993
Practice Address - Fax:707-566-0912
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA313251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice