1184724650 NPI number — DR. PRESTON COOPER DDS

Table of content: DR. PRESTON COOPER DDS (NPI 1184724650)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184724650 NPI number — DR. PRESTON COOPER DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOPER
Provider First Name:
PRESTON
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184724650
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1215 MILITARY RD
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
BENTON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-315-5574
Provider Business Mailing Address Fax Number:
501-315-5579

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1215 MILITARY RD
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-315-5574
Provider Business Practice Location Address Fax Number:
501-315-5579
Provider Enumeration Date:
09/25/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  2248 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)