Provider Demographics
NPI:1063037315
Name:COOLEY, CHARLES ROBERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ROBERT
Last Name:COOLEY
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 1:2630 S EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6704
Mailing Address - Country:US
Mailing Address - Phone:208-888-0625
Mailing Address - Fax:208-888-9128
Practice Address - Street 1:2630 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6704
Practice Address - Country:US
Practice Address - Phone:208-888-0625
Practice Address - Fax:208-888-9128
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-5153122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDD5153OtherSTATE LICENSE NUMBER