Provider Demographics
NPI:1841535788
Name:BRYDEN MCCORMICK DDS
Entity type:Organization
Organization Name:BRYDEN MCCORMICK DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYDEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-887-5030
Mailing Address - Street 1:231 N JUDD PKWY NE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-2385
Mailing Address - Country:US
Mailing Address - Phone:919-887-5030
Mailing Address - Fax:919-887-5022
Practice Address - Street 1:231 N JUDD PKWY NE
Practice Address - Street 2:SUITE 101
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-2385
Practice Address - Country:US
Practice Address - Phone:919-887-5030
Practice Address - Fax:919-887-5022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8580122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910287Medicaid