Provider Demographics
NPI:1043382096
Name:COOPER, JAVON SELIG (DDS)
Entity Type:Individual
Prefix:
First Name:JAVON
Middle Name:SELIG
Last Name:COOPER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 YANCEYVILLE ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-6958
Mailing Address - Country:US
Mailing Address - Phone:336-510-5813
Mailing Address - Fax:336-510-5812
Practice Address - Street 1:1515 YANCEYVILLE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6958
Practice Address - Country:US
Practice Address - Phone:336-379-9939
Practice Address - Fax:336-510-5812
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6552122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9002FOtherBCBS NC PROVIDER
NC799002FMedicaid