Active NPI
Mason McGillicuddy, DDS
- Dentist
- Grand Rapids, MI
National Provider Identifier
1124557699
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- UNKNOWN
- Practice address
- 100 Cherry St SE
Grand Rapids, MI 49503-4526 - Phone
- (616) 965-8200
- Fax
- (616) 940-5366
- NPI assigned
- Jun 8, 2017
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | UNKNOWN | MI | Primary |
Addresses
Primary practice location
100 Cherry St SE
Grand Rapids, MI 49503-4526
Mailing address
100 Cherry St SE
Grand Rapids, MI 49503-4526
Phone (616) 965-8200
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MI
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20170918003460 | MI | Order and Referring Only - Dentist | 7810261658 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| UNKNOWN | MI | MD | Medical Microbiology Physician |
Interoperability endpoints
- mason.mcgillicuddy.p1@direct.cherryhealth.nextgenshare.com
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1496880000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1496880000000",
"number": "1124557699",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "100 CHERRY ST SE",
"city": "GRAND RAPIDS",
"state": "MI",
"postal_code": "495034526",
"telephone_number": "616-965-8200",
"fax_number": "616-940-5366"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "100 CHERRY ST SE",
"city": "GRAND RAPIDS",
"state": "MI",
"postal_code": "495034526",
"telephone_number": "616-965-8200",
"fax_number": "616-940-5366"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MCGILLICUDDY",
"first_name": "MASON",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2017-06-08",
"last_updated": "2017-06-08",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "MI",
"license": "UNKNOWN",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Grand Rapids, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 8, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.