NPIMap

Individual provider Active NPI

Matthew D. McKissock, D.M.D.

  • Dentist
  • Windermere, FL
National Provider Identifier
1104049543
Registry record updated Sep 22, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
License
DN14895 Issued in FL
Practice address
4769 The Grove Dr.
Suite 100
Windermere, FL 34786
Phone
(407) 909-1099
Fax
(407) 909-1599
NPI assigned
Apr 11, 2007
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Sep 22, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dentist 122300000X DN14895 FL Primary

Addresses

Primary practice location

4769 The Grove Dr.
Suite 100
Windermere, FL 34786

Mailing address

4769 The Grove Dr.
Suite 100
Windermere, FL 34786
Phone (407) 909-1099

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled

State licenses

LicenseStateTypeSpecialty
DN14895FLMDDentist

Practice roles

OrganizationSpecialtyStatusNew patients
McKissock Corp Dentist Past Accepting new patients
McKissock Corp. Dentist Past Accepting new patients

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176249600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1663804800000",
    "number": "1104049543",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4769 THE GROVE DR.",
            "address_2": "SUITE 100",
            "city": "WINDERMERE",
            "state": "FL",
            "postal_code": "34786",
            "telephone_number": "407-909-1099",
            "fax_number": "407-909-1599"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4769 THE GROVE DR.",
            "address_2": "SUITE 100",
            "city": "WINDERMERE",
            "state": "FL",
            "postal_code": "34786",
            "telephone_number": "407-909-1099",
            "fax_number": "407-909-1599"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MCKISSOCK",
        "first_name": "MATTHEW",
        "middle_name": "D.",
        "name_prefix": "Dr.",
        "credential": "D.M.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-04-11",
        "last_updated": "2022-09-22",
        "certification_date": "2022-09-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "FL",
            "license": "DN14895",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Windermere, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 22, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.