Provider Demographics
NPI:1104049543
Name:MCKISSOCK, MATTHEW D (DMD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:D
Last Name:MCKISSOCK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:407-909-1599
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:407-909-1599
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN14895122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist