Provider Demographics
NPI:1710134671
Name:MCCORMACK, JENNIFER (DMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MCCORMACK
Suffix:
Gender:F
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:PO BOX 597
Mailing Address - Street 2:53 S LAUREL ST, 2ND FLOOR
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-0433
Mailing Address - Country:US
Mailing Address - Phone:856-451-4700
Mailing Address - Fax:
Practice Address - Street 1:319 W LANDIS AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-8101
Practice Address - Country:US
Practice Address - Phone:856-691-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-22
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02381100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist