Provider Demographics
NPI:1366525164
Name:MCCORD, GARY L (DMD)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:L
Last Name:MCCORD
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:P.O BOX 267
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41004
Mailing Address - Country:US
Mailing Address - Phone:606-735-3114
Mailing Address - Fax:606-735-3114
Practice Address - Street 1:224 FRANKFORT ST
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41004-8306
Practice Address - Country:US
Practice Address - Phone:606-735-3114
Practice Address - Fax:606-735-3114
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5151122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60051513Medicaid
KY610980267OtherEMPLOYEE FEDERAL I.D