1073722203 NPI number — M. STACY COOK, DMD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073722203 NPI number — M. STACY COOK, DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
M. STACY COOK, DMD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1073722203
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 280
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEAKESVILLE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39451-0280
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-394-2467
Provider Business Mailing Address Fax Number:
601-394-2468

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
403 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEAKESVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-394-2467
Provider Business Practice Location Address Fax Number:
601-394-2468
Provider Enumeration Date:
05/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
STACY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
601-394-2467

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  2870 95 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 73003671 . This is a "BCBS AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 09015334 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 425495231B . This is a "BCBS OF MS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com