1912071770 NPI number — MRS. MARYLIN MARIE COOPER JENKINS DDS

Table of content: MRS. MARYLIN MARIE COOPER JENKINS DDS (NPI 1912071770)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912071770 NPI number — MRS. MARYLIN MARIE COOPER JENKINS DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOPER JENKINS
Provider First Name:
MARYLIN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COOPER
Provider Other First Name:
MARYLIN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1912071770
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 N KING STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEQUIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-379-0664
Provider Business Mailing Address Fax Number:
830-379-3003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 N KING STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEQUIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-379-0664
Provider Business Practice Location Address Fax Number:
830-379-3003
Provider Enumeration Date:
11/20/2006

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:  16819 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 16819 . This is a "TEXAS STATE DENTAL BOARD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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