1073722203 NPI number — M. STACY COOK, DMD

Table of content: (NPI 1073722203)

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