Provider Demographics
NPI:1215117866
Name:MCCORMACK, BRADLEY L (DDS)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:L
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 1:34155 CENTER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH RIDGEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44039-3221
Mailing Address - Country:US
Mailing Address - Phone:440-327-7950
Mailing Address - Fax:440-327-1825
Practice Address - Street 1:34155 CENTER RIDGE RD
Practice Address - Street 2:
Practice Address - City:NORTH RIDGEVILLE
Practice Address - State:OH
Practice Address - Zip Code:44039-3221
Practice Address - Country:US
Practice Address - Phone:440-327-7950
Practice Address - Fax:440-327-1825
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21626122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3159282Medicaid