Basic Information
| Provider Information | |||||||||
| NPI: | 1710134671 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCORMACK | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 597 | ||||||||
| Address2: | 53 S LAUREL ST, 2ND FLOOR | ||||||||
| City: | BRIDGETON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083020433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564514700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 319 W LANDIS AVE | ||||||||
| Address2: | |||||||||
| City: | VINELAND | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083608101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566913300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2008 | ||||||||
| LastUpdateDate: | 02/16/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 22DI02381100 | NJ | Y | Dental Providers | Dentist |
No ID Information.