Provider Demographics
NPI:1992962070
Name:MOCKNICK, MICHAEL CHARLES (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:MOCKNICK
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 1:6845 ELM ST
Mailing Address - Street 2:SUITE 509
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-6007
Mailing Address - Country:US
Mailing Address - Phone:703-734-0334
Mailing Address - Fax:
Practice Address - Street 1:6845 ELM ST
Practice Address - Street 2:SUITE 509
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-6007
Practice Address - Country:US
Practice Address - Phone:703-734-0334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-17
Last Update Date:2008-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401008063122300000X
MD91221223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223E0200XDental ProvidersDentistEndodontics