Provider Demographics
NPI:1073722203
Name:M. STACY COOK, DMD
Entity Type:Organization
Organization Name:M. STACY COOK, DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-394-2467
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:LEAKESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39451-0280
Mailing Address - Country:US
Mailing Address - Phone:601-394-2467
Mailing Address - Fax:601-394-2468
Practice Address - Street 1:403 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEAKESVILLE
Practice Address - State:MS
Practice Address - Zip Code:39451
Practice Address - Country:US
Practice Address - Phone:601-394-2467
Practice Address - Fax:601-394-2468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2870 95122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL73003671OtherBCBS AL
MS09015334Medicaid
MS425495231BOtherBCBS OF MS