Provider Demographics
NPI:1831459551
Name:MCKISSOCK CORP
Entity Type:Organization
Organization Name:MCKISSOCK CORP
Other - Org Name:WINDERMERE DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:MCKISSOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-909-1099
Mailing Address - Street 1:4769 THE GROVE DR.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786
Mailing Address - Country:US
Mailing Address - Phone:407-909-1099
Mailing Address - Fax:
Practice Address - Street 1:4769 THE GROVE DR.
Practice Address - Street 2:SUITE 100
Practice Address - City:WINDERMERE
Practice Address - State:FL
Practice Address - Zip Code:34786
Practice Address - Country:US
Practice Address - Phone:407-909-1099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCKISSOCK CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16810122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty