Provider Demographics
NPI:1053309435
Name:COOPER, ROBERT EARL (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EARL
Last Name:COOPER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 FAIRFAX AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4905
Mailing Address - Country:US
Mailing Address - Phone:502-895-1171
Mailing Address - Fax:
Practice Address - Street 1:111 FAIRFAX AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4905
Practice Address - Country:US
Practice Address - Phone:502-895-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY57651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice