Provider Demographics
NPI:1891007225
Name:MCCORMACK, MICHAEL SHAWN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SHAWN
Last Name:MCCORMACK
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 1:265 N PARAMOUNT LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-2116
Mailing Address - Country:US
Mailing Address - Phone:575-837-7055
Mailing Address - Fax:
Practice Address - Street 1:1713 10TH ST STE A
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5027
Practice Address - Country:US
Practice Address - Phone:575-439-5439
Practice Address - Fax:575-439-0162
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-14
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002019721223G0001X
NMDD55531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500624011Medicaid
CO78337372Medicaid