Provider Demographics
NPI:1962668368
Name:MCCORMICK, HOLLY JEAN (EFDA)
Entity type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:JEAN
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:EFDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51468 SE OAK GROVE DR
Mailing Address - Street 2:
Mailing Address - City:SCAPPOOSE
Mailing Address - State:OR
Mailing Address - Zip Code:97056-4428
Mailing Address - Country:US
Mailing Address - Phone:503-341-6316
Mailing Address - Fax:
Practice Address - Street 1:17675 SW TUALATIN VALLEY HWY
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4443
Practice Address - Country:US
Practice Address - Phone:503-259-3169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA5404126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant