Provider Demographics
NPI:1710954623
Name:MCCORMICK, KENNETH J (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
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 1:540 S PARKER ST
Mailing Address - Street 2:
Mailing Address - City:MARINE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48039-3585
Mailing Address - Country:US
Mailing Address - Phone:810-765-1440
Mailing Address - Fax:810-765-3752
Practice Address - Street 1:540 S PARKER ST
Practice Address - Street 2:
Practice Address - City:MARINE CITY
Practice Address - State:MI
Practice Address - Zip Code:48039-3585
Practice Address - Country:US
Practice Address - Phone:810-765-1440
Practice Address - Fax:810-765-3752
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI126581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice