Provider Demographics
NPI:1750620795
Name:MCCOY, MALLORY NORTHCUTT (DMD)
Entity type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:NORTHCUTT
Last Name:MCCOY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MALLORY
Other - Middle Name:JEAN
Other - Last Name:NORTHCUTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:3802 MARGRAVE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-3945
Mailing Address - Country:US
Mailing Address - Phone:843-858-3190
Mailing Address - Fax:
Practice Address - Street 1:1335 KINARD ST
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-3037
Practice Address - Country:US
Practice Address - Phone:803-276-3367
Practice Address - Fax:803-276-6075
Is Sole Proprietor?:No
Enumeration Date:2013-02-12
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC8206122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program